Crystal Pines Rehab & Hcc
335 North Illinois Avenue, Crystal Lake, IL 60014 · For profit - Corporation · 110 certified beds · (815) 459-7791 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jun 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 5 actual-harm citations
- inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (48) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $130,776 in federal fines (most recent 2026-05-06)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- about 17% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 24.2% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.5% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.8% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 42.7% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 28.2% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.5% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.1% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.5% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 56.7% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.8% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 2.3% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.65 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.68 | 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.
41.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 95 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 27.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 33 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% 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 | 41.1%CMS range 31.7–51.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.0%CMS range 9.2–16.6 | 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 | 27.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 24.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.5% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 | 9.1% | 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 | 3.6% | 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 | 6.0%CMS range 3.3–11.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.17 | 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 110 beds and averages 82.6 residents a day — about 75% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.15 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.98 hrs/resident/day on weekends vs 3.22 on weekdays — 8% thinner on weekends. RN hours go from 0.89 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
48 citations, most serious first. The 17 most serious are shown; the remaining 31 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-11-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure 1 of 4 residents (R8) was free from verbal and mental abuse when a staff member repeatedly told R8 that his genitalia was tiny and escalated to saying R8's genitalia is useless and should just be cut off. This verbal assault resulted in R8 feeling very hurt, angry, feeling pain, and significant distress from the verbal abuse. This failure applies to 1 of 4 residents (R8) reviewed for mental abuse in the sample of 14. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/7/24 when R8 notified V2 (Director of Nursing) and V1 (Administrator) that V10 (Certified Nursing Assistant- CNA) repeatedly told R8 that his genitalia was tiny and escalated to V10 saying R8's genitalia is useless and should just be cut off. V15 (Assistant Administrator) and V17 (Regional [NAME] President) were notified of the Immediate Jeopardy on 11/14/24 at 8:14 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice…
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 before2026-05-06 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 enteral feeding was administered as ordered 1 of 3 residents (R1) reviewed for enteral feedings in the sample of 3. This failure resulted in R1's admission to the acute care hospital for treatment of aspiration pneumonia.The findings include:R1's face sheet showed she was admitted to the facility 9/24/2020 with diagnoses to include hypokalemia, dysphagia, gastrostomy status, gastrointestinal hemorrhage, chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder. R1's 6/26/25 facility assessment showed she had severe cognitive impairment, was dependent on staff for all cares, and had a feeding tube.R1's July 2025 Physician Order Sheet showed an order started 4/18/25, Enteral Feed Order: in the evening. Administer Novasource via PEG-tube at 60 cc/hr. On at 6:00 PM off at 6:00 AM. Total volume to be infused 720cc in 24 hours. May turn off for short periods of time for care and services. Verify total volume infused prior to turning off.R1's Care Plan initiated 11/29/23 showed, [R1] requires…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2026-04-20 · 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 safely transport a resident. This failure resulted in R1 falling from her wheelchair during the transport and sustaining a 5 centimeter (cm.) laceration to her forehead requiring emergency medical attention, 11 sutures and hospitalization. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 4. This past noncompliance occured from 3/16/26 to 3/23/26. Findings include: R1's face sheet shows R1's diagnoses including Alzheimer's Disease, muscle weakness, and a non-displaced type 2 dens fracture.R1's current care plan shows R1 is at risk of falls and requires staff assistance with toileting and transfers. R1's nursing progress note dated 3/16/26 at 9:12 PM, shows that R1 had a fall out of her wheelchair while being taken to the bathroom by a CNA (Certified Nursing Assistant). R1 fell forward out of her wheelchair and hit her face on the floor. A laceration was noted above R1's left eyebrow, 911 was called and R1 was sent to a local emergency room for treatment.A State Reportable Incident form completed by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-10-14 · 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 ensure a residents bed was maintained to ensure no hazards were present for one of three residents (R1) reviewed for injury in the sample of three. This failure resulted in R1 experiencing a large skin tear from exposed sharp metal on the bed, requiring R1 being sent to the local hospital and requiring 12 sutures to the wound.Findings include:R1's Face Sheet dated October 14, 2025, shows R1 was admitted to the facility on [DATE], with a diagnosis of senile degeneration of the brain. R1's Care Plan initiated September 1, 2025, shows R1 has an activity of daily living self-care performance deficit related to dementia and anxiety disorder. The facility's State Report dated October 8, 2025, shows on October 7, 2025, a certified nursing assistant (CNA) was transferring R1 from her wheelchair to her bed with a one-person assist per her care-plan. After R1 sat on the edge of the bed, the CNA observed fresh blood on the floor and noted that R1 had a laceration…
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 before2024-06-05 · 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 a resident who is a high risk for falls was supervised and ensure fall interventions were in place. This failure resulted in R6 falling forward out of her wheelchair and hitting her head on the floor. R6 sustained a forehead laceration requiring transport to the hospital and R6 requiring sutures. This applies to 1 of 18 residents (R6) reviewed for safety in the sample of 18. Findings include: R6's face sheet shows R6's diagnoses including unspecified dementia, unspecified psychosis, anxiety, delusional disorders, repeated falls, peripheral vascular disease and hallucinations. R6's Fall Risk assessment dated [DATE] shows she is a HIGH risk for falls. R6's careplan revised on 6/3/24 shows she is a risk for falls, due to weakness, balance problems, dementia, urinary bladder incontinence, psychotropic/opiate medication use and has a history of falls. Interventions include anti-tippers on front of wheelchair's, anti-slip mat under…
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 before2023-07-19 · 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
Based on interview and record review the facility failed to ensure a resident was safely assisted to re-position in bed. This failure contributed to (R17) sustaining abrasions to her toes which became gangrene requiring wound care, hospitalization, and recommended amputation to her right toes. This applies to 1 of 7 residents reviewed for safety in the sample of 17. The findings include: On 7/17/23 at 9:56 AM, R17 was in her bed. From the doorway R17's right foot was visible. Her great toe and the next 3 toes were observed to be black in color. R17 was attempted to be interviewed but was cognitively impaired and could only ask the surveyor to please be careful and not touch her toes. On 7/17/23 at 11:30 AM, V17 (R17's son) said his mom R17 has had the wound to her toes for quite some time possible back to March 2023. V17 said the facility never gave him an explanation of how these (traumatic) wounds started but he knows they started out as scrapes with scabs on them and have progressed to now requiring a vascular surgeon and amputation has been discussed. R17 said his mom does not…
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 before2023-07-19 · 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
Based on interview and record review the facility failed to ensure monthly dietary assessments were completed for a resident on a feeding tube (R55) and for a resident with non- pressure wounds with a history of significant weight loss (R17) and failed to notify the Dietician of continued significant weight loss for a resident (R17). These failures contributed to a delay in implementing additional dietary interventions for R17 following a significant weight loss of 9.09% in 2 months. This applies to 2 of 12 residents (R17, R55) reviewed for weight loss in the sample of 17. The findings include: 1. R17's face sheet shows she has diagnoses including: Unspecified Dementia, Major Depression, Type 2 Diabetes, and anxiety disorder. R17's weight trending history is as follows: On 7/29/22, R17 weighed 248.1 lbs. On 7/5/23, R17 weighed 165.2 pounds which is an overall 33.41 % -82.9-pound (lb.) loss in 1 year. On 1/15/23, R17 weighed 204.6 lbs. On 7/5/23, R17 weighed 165.2 pounds which is a 19.26 % -39.4 lb. loss in 6 months. On 4/1/23, R17 weighed 193.6 lbs. On 5/30/23, R17 weighed 176.0…
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 before2026-06-11 · 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 ensure a resident was free from misappropriation of property for 1 of 3 residents (R1) reviewed for abuse in the sample of 3. This past non-compliance occurred from 5/11/26 to 6/10/26.The findings include: R1's admission records shows he was admitted to the facility on [DATE]. R1's quarterly resident assessment and care screening dated 4/23/26 documents he was cognitively intact. R1s progress notes for 5/22/26 document he expired in the facility.On 6/11/26 at 9:00 AM, V1 (Administrator) said he was informed by a staff member on 6/4/26 a local restaurant employee had informed him of a staff member possibly using a resident's credit card. He said V4 (R1's nephew) had called the restaurant inquiring about receipts he had found going through paperwork. On 6/11/26 at 10:30 AM, V4 (R1's nephew) said when he was going through R1's papers he found receipts from a local restaurant dated 5/11/26. One receipt had charges for $58 and included shrimp dinners and 4…
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 · D2025-12-03 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to ensure residents are treated with dignity and respect. This applies to 2 of 4 residents (R1, R2) reviewed for resident rights in the sample of 4. The findings include: On 12/2/25 at 9:24 AM, R1 was in her room sitting in her wheelchair, sitting next to her roommate R2. R1 said on 11/28/25, there was a young kid V3 (Agency CNA) who came into her room to assist her in the bathroom. R1 said it was the first time she had seen V3, he was wearing street clothes a black shirt, no name tag and did not introduce himself. R1 said he looked like he would be cleaning the floors wearing a black t-shirt with writing on it. I don't think that's professional attire, he did not announce who he was and just came into our room and took me to the bathroom. R1 said she felt uncomfortable, he didn't explain who he was and she did not know he was a CNA. On 12/2/25 at 9:28 AM, R2 was in her room sitting in her wheelchair, sitting next to R1. R2 said on 11/28/25, V3 entered the room, did not knock or introduce himself. V3 was not wearing a name tag…
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 before2025-11-21 · 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 ensure a resident's safety during an outdoor activity. This applies to 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 5.The findings include:R2's electronic face sheet printed on 11/24/25 showed R2 has diagnoses including but not limited to type 2 diabetes, constipation, CHF, vascular dementia without behaviors, repeated falls, and peripheral vascular disease.R2's facility assessment dated [DATE] showed R2 had mild cognitive impairment.The facility's incident report dated 11/15/25 showed, This writer was notified by the weekend staff nursing supervisor that (R2) received a bite from a visiting domesticated horse and received a small laceration to the hand. The horse was under the supervision of its handler when the incident occurred .R2's progress notes dated 11/15/25 showed, Resident attempted to feed a horse during activities, but was accidently bit on the left 4th digit. She sustained an abrasion .resident was complaining…
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 before2025-08-20 · 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 a resident remained free of sexual abuse. This applies to one of three residents (R5) in the sample of eight reviewed for abuse. Findings include:The facility face sheet for R5 shows diagnoses to include dementia and psychosis. The facility assessment dated [DATE] shows R5 to have severe cognitive impairment and requires maximum staff assistance with her activities of daily living, and uses a wheelchair for ambulation.The facility face sheet for R4 shows diagnoses to include Parkinson's Disease, depression and psychotic disorder. The facility assessment dated [DATE] shows R4 to be cognitively intact and requires supervision for his activities of daily living and uses a wheel chair for his ambulation. The facility state report dated 8/9/2025 shows an incident between R4 and R5 while in the dining room of the facility. A staff observed the two residents sitting closely to each other and the male residents (R4) arm was moving back and forth over 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 before2025-04-29 · 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 perform thorough pressure ulcer assessments and initiate a baseline care plan for a resident admitted to the facility with a pressure ulcer for 1 of 1 residents (R1) reviewed for pressure ulcers in the sample of 4. Findings include: R1's Facesheet dated 4/24/25 showed she was admitted to the facility 10/28/24 with diagnoses to include, but not limited to: COVID-19, generalized muscle weakness, hypothyroidism, diabetes, gastro-espophageal reflux disease (GERD), unspecified cirrhosis of the liver, and gout. R1's Nursing admission Assessment completed dated 10/28/24 showed she had pressure to her sacrum. This document did not provide any further description or measurements of R1's pressure ulcer to her sacrum. R1's Progress Notes did not contain a detailed pressure ulcer assessment for R1's initial pressure ulcer and weekly assessment. R1's Electronic Medical Record (EMR) did not contained a thorough initial or weekly assessment of R1's pressure wound to…
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 before2025-04-15 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 dietary staff are properly trained. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). On 4/15/25 at 8:30 AM, V1 said the facility does not currently have a dietary manager and V8 (Former Dietary Manager) left approximately two to three weeks ago. On 4/15/25 at 11:00 AM, V11 (Regional Director of Operations- Kitchen) said he and his company have been overseeing the facility since July or August of 2024. V11 said the facility is responsible for hiring and training their own in-house employees including dietary aides, cooks, and a dietary manager. V11 said his company provides the facility access to a menu program that provides menus, recipes, tray tickets, policies and procedures, and education material.…
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 before2025-04-15 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure correct food service scoops were used to serve mashed potatoes. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). On 4/15/25 at 11:40 AM, V4 (Cook) said the food supplier did not bring the lunch meal on time to serve the country fried steak on Monday. V4 said for lunch on 4/15/25 they will be serving country fried steak with gravy, mashed potatoes, gravy, and a breadstick. V4 said V4 and other cooks usually get the scoops set up and ready for serving and the dietary aides will serve lunch. V4 showed this surveyor where the binder was that listed the portion and scoop sizes to use for each meal and stated that the dietary aides also know where it is and have access to it when needed. On 4/15/25 at 11:25 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.
- Potential for harm · Fcited before2025-04-15 · 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 record review the facility failed to ensure employees practiced safe food handling practices resulting in risks of cross-contamination. This has the potential to affect all 73 residents in the facility. Findings include: Facility Data Sheet dated 4/15/25 shows the facility has a total census of 73 residents. On 4/15/25 at 12:10 PM, V1 (Interim Administrator) said the facility does not currently have any residents that receive a tube feeding or have an order of NPO (nothing by mouth). 1. On 4/15/25 between 9:15 AM and 9:30 AM, V7 (Dietary Aide) was continually observed doing dishes at the dish machine wearing gloves. V7 started by breaking down breakfast trays, discarding food debris and waste, and placing all trays, plate tops, cups, and utensils into dish racks. When the dish rack was full, V7 would place the dish rack into the dish machine and pull down the handle to run the automatic run cycle. When the cycle finished, V7 would pull the dish rack out of the dish machine and place the rack on the out-feed table to dry. V7 continued this process…
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 before2025-02-24 · 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 ensure a resident was free from misappropriation. This applies to 1 of 4 residents (R1) reviewed for misappropriation in the sample of 4. The findings include: R1's Minimum Data Set, dated [DATE] shows R1 scored a 15 out of 15 on her brief interview for mental status test indicating R1 is cognitively intact. On 2/24/25 at 10:00 AM, R1 said during the week of February 10th through February 15th, V4 (R1's Family Member) visited and gave R1 two twenty-dollar bills. R1 said she placed the two bills with the rest of R1's money in the side pocket of her purse that uses a drawstring to close. On 2/24/25 at 11:53 AM, V4 said after giving R1 the money, R1 and V4 counted the money together and V4 watched R1 put the money into the side pocket of the purse and closed the drawstring closure. Facility sign-in sheet for visitors shows that V4 visited R1 on 2/11/25 and again on 2/14/25. On 2/24/25 at 10:00 AM, R1 said on the morning of 2/15/25, R1 asked V5 (Agency…
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 before2025-01-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure care was provided to a resident in a dignified manner for 1 of 3 residents (R3) reviewed for resident rights in the sample of 6. The findings include: On 1/8/25 at 10:12 AM, R3 was sitting up in bed. R3 said she had been on isolation for COVID. R3 said one night a CNA (Certified Nursing Assistant - V11) came in her room. R3 stated, I don't know her name, but I think [V1 - Administrator] knows it. I talked to her (V1) about it. Anyways, the CNA was changing me and I told her that I have pain in my knees and she needs turn me at pushing on my hips. She kept pushing on my legs and it hurt, so I was telling her not to touch my knees. She kept making comments that she had a headache and I was yelling. I wasn't yelling, but I was letting her know that she was hurting my legs. When she turned me, she made a comment about me being a very big girl. I know I'm overweight and I don't need to be reminded. I thought that was a rude comment. 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.
Show the remaining 31 citations
- Potential for harm · Dcited before2025-01-08 · 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 observation, interview, and record review the facility failed to ensure a resident's was free of misappropriation for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. The findings include: On 1/7/25 at 10:13 AM, R2 was sitting up in bed with her cell phone resting on the overbed table, in front of her. R2 said on 12/28/24 she was taking a nap. R2 said she woke up and her cell phone was missing. R2 said she figured (V4 - Agency CNA (Certified Nursing Assistant) had it, but she wasn't sure. R2 stated, The first time she saw [V4] was 4 days before. She (V4) asked me if she could use my phone and I gave her permission that day, but she used it in front of me. Then she came back on 12/28/24 and asked me if she could use my phone. I told her no a few times. When I woke up from my nap, my cell phone was gone. I called the CNA to report my cell phone was gone and she looked all over the place. They looked and looked and couldn't find it. I told the CNA (I don't remember her name) that V4 had 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 before2024-12-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's urinary catheter was changed when is was dirty and clogged. The facility failed to keep the catheter drainage bag below the level of the bladder and off the bed for 2 of 3 residents (R1, R3) reviewed for catheters in the sample of 3. Findings include: 1. R1's Face Sheet dated 12/10/24 showed he was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, left hand contracture, pressure ulcer, type 2 diabetes mellitus, severe protein calorie malnutrition, hyperlipidemia, obstructive sleep apnea, spastic hemiplegia of the left side, hypertension, atrial fibrillation, aphasia, left sided hemiplegia, dysphagia, obstructive and reflux uropathy, and gastrostomy. The Physician Orders dated 12/10/24 showed, urinary catheter 16 French, 10 ml (milliliter). Change indwelling urinary catheter as needed for blockage or dislodgement. Change catheter drainage bag as needed for leaking. The Treatment…
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 · D2024-11-27 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop a comprehensive care plan that provided interventions for a resident's known behaviors for 1 of 9 residents (R2) reviewed for Care Plans in the sample of 9. Findings include: R2's Careplan printed on 11/25/24 did not address R2's behavior of requesting staff to buy things for her or provide interventions for staff to implement when the behaviors are present. On 11/25/24 at 9:45AM, R2 said, I use to have a CNA-Certified Nursing Assistant that would buy things from an on-line retailer for me. We both eventually got in trouble for it. I have a history of having problems with handling money. On 11/27/24 at 9:35AM, V3 CNA said, R2 requested I buy her something. I told her I could not. R2 insisted and gave me the money. I intended to give it back later in my shift. I got busy and forgot. I gave it back to her when I returned the next day. I was not informed R2's behavior of continually requesting staff to buy things for her. On 11/25/24 at 9:54 AM, V1 Administrator said, I dispense the funds for 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 before2024-11-14 · 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 immediately report staff to resident verbal and mental abuse to the Administrator and local law enforcement for 1 of 4 residents (R8) reviewed for abuse in the sample of 9. Findings include: A facility provided investigation summary completed by V1 (Administrator) shows on 11/7/24, R8 reported to V2 (Director of Nursing/DON) that a former Certified Nursing Assistant (CNA) identified as V10 had been making fun of his genitalia. V10 (CNA) was referring to R8's penis as being tiny and it was useless and should just be cut off. The investigation shows that V9 (former CNA) confirmed that V10 had made fun of R8 calling him tiny and V9 said she had told V10 that this was sexual harassment and he should stop. The investigation shows V9 reported she had thought V10 had stopped doing this to R8. On 11/13/24 at 9:10 AM, R8 said that V10 had been making fun of his penis size but he did not report it to anyone because he did not want R8 to lose his job. On 11/13/24 at 9:26 AM, V9 (CNA) said that she was present in the room months ago…
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 before2024-07-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure an alleged physical abuse was immediately reported to the administrator for 1 of 4 residents (R1) reviewed for allegations of abuse in the sample of 4. Findings include: R1's Face Sheet shows that he was admitted to the facility on [DATE]. On 7/18/24 at 1:03 PM, V13 (R1's Family Member) said that about a month ago, R1 called her and said that he fell out of his wheelchair and a (specific race) male Certified Nursing Assistant (CNA) came into his room and reprimanded him and picked him up and pushed him against the wall and he fell again. V13 said that she went to the facility and spoke with the head nurse about the situation. V13 said, I told her exactly what I just told you. V13 said that V2 (Director of Nursing) left the room and came back about 15 minutes later and said that it did not happen. On 7/18/24 at 11:30 AM, R3 (who resides in the room next to R1) said that he heard R1 complaining about V7 (CNA) on 7/4/24. R3 said that he heard R1…
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 · E2024-06-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
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 residents oxygen equipment was changed and labeled for 4 of 9 residents (R4, R14, R24, R34) reviewed for oxygen use in the sample of 18. Findings include: 1. On 6/3/24 at 9:59 AM, R4's oxygen tubing and humidification water bottle, connected to the oxygen concentrater were not dated. On 6/3/24 at 10:16 AM, R4 was up in her wheelchair with a portable oxygen tank. R14 was wearing a nasal canula tubing which was undated. R4's June Physician orders shows Oxygen Tubing - Change Weekly every night shift every Sunday for infection control and Oxygen at 2 L/min via nasal canula, PRN. Maintain saturation >90% as needed for Anxiety and congestive heart failure. On 6/4/24 at 12:52 PM, V11 Licensed Practical Nurse said oxygen tubing is changed every Sunday on night shift, both the tubing and the bubbler, for infection control. V11 said the tubing and bubbler should be labeled and dated to show when they were changed. 2. On 6/3/24 at 9:19 AM, R14 was in bed with a nasal canula on. R14's oxygen tubing was not dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-06-05 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility to administer medications at the prescribed time. This applies to 4 of 18 residents (R47, R70, R28, R30) in sample of 18 reviewed for medication administration. The findings include: 1. On 6/3/2024 at 10:52AM, R47 said there was a nurse call in on Saturday (6/1/2024) and her medications were given late. R47 said her morning medications are normally given around 9:00AM, but on Saturday were given between 2:00PM - 2:30PM. R47 is alert and oriented. On 6/5/2024 at 9:52AM, V9 Staffing Coordinator said there was a nurse call in on Saturday 6/1/2024 for the morning shift. On 6/4/2024 at 1:20PM, V2 Director of Nursing (DON) said medications should be given one hour before or after the scheduled time. R47's Medication Administration (Admin) Audit Report dated 6/1/2024 shows an order for Metoprolol Tartrate Oral Tablet (Antihypertensive) 25 milligrams (mg) give 1 tablet by mouth two times a day. Scheduled date/time was 6/1/2024 at 9:00AM, administered date/time 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 · E2024-06-05 · 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 and serve food to meet residents' needs for four of 18 residents (R28, R29, R3, R8) reviewed for food in the sample of 18. 1. R28's admission Record dated June 5, 2024 shows she was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism of unspecified cerebral artery. R28's Order Summary Report dated June 5, 2024 shows an order for regular texture diet, no cranberry juice, and no green leafy vegetables. R28's order summary report shows that R28 is on coumadin (blood thinner). On June 4, 2024 at 10:15 AM, during resident council meeting, R28 said that she is not supposed to eat green leafy vegetables because she is on coumadin. R28 said the green leafy vegetables thickens her blood. R28 said she gets green leafy vegetables frequently. R28 said she got spinach on her lunch tray on June 3, 2024. R28 said she did not receive any other vegetable as an alternative to the spinach. The facilities…
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 · D2024-06-05 · 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 the prescribed treatment was applied to a resident with Moisture Associated Skin Damage. This applies to 1 of 18 residents (R13) reviewed for quality of care in the sample of 18. Findings include: R13's Physician Order Summary (P.O.S.) dated June 2024 shows orders wound care: left and right gluteal: cleanse with wound cleanser, gently pat dry. Apply collagen to wound bed, cover with large calcium sheet to cover wound areas not covering anus. R13's Wound Evaluation Non-Pressure Evaluation Report dated 5/27/24 documents right buttock wound Moisture Associated Skin Damage (MASD), bloody drainage, measuring 6.3 cm (centimeters) x 7.6 cm x 01.cm. Description of peri wound bed: macerated, reddened and denuded. R13's Wound Evaluation Non-Pressure Evaluation Report dated 5/27/24 documents left buttock wound MASD, bloody drainage, measuring 5.9 cm x 6.2cm x 0.1 cm. Description of peri wound: macerated, reddened and denuded. On 6/3/24 at 10:41 AM, V5 and V6 (Both Certified Nursing Assistant's-CNA's) provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · 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
Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a history of pressure injuries for 1 of 4 residents (R75) reviewed for pressure in the sample of 18. Findings include: On 06/03/24 at 09:52 AM, R75 was in bed on his back with his heels flat on the bed. R75's feet were up against the foot board with a pillow in between his feet and the foot board. On 6/4/24 at 12:50 PM, R75 was in bed on his back with his heels flat on the mattress. There were no heel boots observed. On 06/04/24 at 12:52 PM, V4 Wound Licensed Practical Nurse said R75 was admitted with a pressure injury to the arch of his foot and one on his heel that have since been resolved. V4 said the interventions for R75 are to float heel/feet of the bed with off loading boots when in bed. V4 said R75 sometimes doesn't like the boots due to being too hot, so then pillows should be used to keep heels off the bed. The pillows should keep the heels off the bed, so the heels aren't touching the mattress. Heels should not be up against…
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 · D2024-06-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess and implement interventions for a resident with contractures for 1 of 7 residents (R75) reviewed for range of motion in the sample of 18. Findings include: On 06/03/24 at 9:51 AM, R75 was in bed with his left arm and hand flat on the bed. R75's left arm/hand was slightly edematous. R75's fingers on his left hand were curled under towards the palms of his hand. R75 shook his head no when asked if he could move his left hand. On 6/4/24 at 10:29 AM, V12 Restorative Certified Nursing Assistant said she was not doing restorative therapy for R75's contracture. On 6/4/24 at 11:00 AM, V13 Regional Registered Nurse said there is no restorative program for R75. R75 has a contraction to his left fingers at the first joint. V13 said she just went and looked at R75's left hand and saw some swelling so she elevated the hand and put rag between his fingers and his palm. V13 said R75 had therapy when he first admitted , but is not on physical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a urinary catheter urine collection bag was positioned off the floor to prevent cross-contamination for 1 of 10 residents (R24) reviewed for urinary catheters in the sample of 18. Findings include: On 6/3/24 at 9:25 AM, R24's urinary catheter bag was full with urine and was resting on the floor under R24's bed. On 6/3/24 at 12:28 PM, R24's urinary catheter bag (still full of urine) was resting on floor. R24 stated they just came in here and put the catheter bag in a privacy bag. On 6/4/24 9:35 AM, R24's urinary catheter bag was resting on floor. On 6/4/24 at 12:52 PM, V11 Licensed Practical Nurse said urinary catheter bags should be placed below the level of the bladder and not on floor. V11 said the urinary catheter bag should not be touching a contaminated surface (the floor) for infection control. R24's Physician Order shows (Urinary) catheter 18 french 30 ml (milliliter) balloon for obstructive and reflux uropathy. The facility's Catheter Care Policy dated January 2017 shows be sure the catheter…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 R75's enteral nutrition bag was labeled for 1 of 4 residents (R75) reviewed for enteral feedings in the sample of 18. Findings include: On 6/3/24 at 9:49 AM, R75's feeding pump was running at 70 ml (millilters)/hr (hour). The enteral feeding bag was labeled with R75's name and a date of 5/31/24. The enteral feeding bag did not contain the name of the contents of the bag or when the feeding was started. R75's Physician Orders dated June 2024 shows Administer Isosource 1.5 via G-tube at 70 cc (cubic centimeters)/hr. On at 1300 (1:00 PM) off at 0900 (9:00 AM). Total volume to be infused 1400 ml in 24 hours. May turn off for short periods of time for care and services. Verify total volume infused prior to turning off. On 6/4/24 at 1:05 PM, V15 Nursing Supervisor said R75 gets Iso-source 1.5 from 1:00 PM to 9:00 AM. V4 stated We pour Iso-source cans into feeding tube bag and then we label the bag with residents name, date of birth , order- Iso Source 1.5, total to infuse, and date and time hung. If the bag…
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 · D2024-06-05 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for three of 18 residents (R70, R28, R30) reviewed for medications in the sample of 18. Findings include: 1. R70's admission Record dated June 5, 2024 shows he was admitted to the facility on [DATE] with diagnoses including duodenal ulcer, congestive heart failure, chronic kidney disease, alcoholic cirrhosis of liver, nausea with vomiting, alcohol abuse, major depressive disorder, anxiety disorder, gastro-esophageal reflux disease, and acute respiratory failure with hypoxia. On June 4, 2024 at 10:15 AM, during resident council meeting, R70 said last Saturday (June 1, 2024) he did not receive his morning medications until about 1:00 PM. R70 said it was a nurse from an agency. R70 said he takes depression medications, anxiety medications, and medicine to keep his ammonia levels down. R70 said if he does not get the medication to keep his ammonia levels down, then he passes out. R70 said he was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff donned all applicable Personal Protective Equipment while providing direct care to a resident with Enhanced Barrier Precautions. This applies to 1 of 18 residents (R13) reviewed for infection control in the sample of 18. The findings include: R13's Physician Order sheets dated June 2024 shows R13's diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, peripheral vascular disease and complete traumatic amputation at level between knee and ankle left and right lower leg. R13's Physician's Order Sheet (POS) shows orders for enhanced barrier precautions related to urinary catheter and wound care every shift wear gloves and gown when providing high contact care. On 6/3/24 at 10:41 AM a sign was posted outside of R13's door. Enhanced Barrier Precautions. V5 and V6 (Both Certified Nursing Assistant's-CNA) donned gloves and did not wear a gown, they transferred R13 from his…
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 before2024-03-26 · 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 a resident in the shower room for one of one resident (R1) reviewed for safety in the sample of 3. This past non-compliance occurred from March 3, 2024 to March 9, 2024. The findings include: R1's face sheet printed on 3/26/24 showed diagnoses including but not limited to dementia, heart disease, unsteadiness on feet, muscle weakness, hypertension, peripheral vascular disease, and repeated falls. R1's facility assessment dated [DATE] showed staff assistance of partial to moderate assistance needed for showering. The same assessment showed supervision to touching assistance needed for sit to standing and walking. R1's care plan showed a focus area related to risk of falls start dated 2/19/24. Interventions included: Ensure that (R1) is wearing appropriate non-skid footwear when ambulating or mobilizing in wheelchair. Do not leave resident in bathroom unattended. R1's progress note dated 3/3/24 and written by V3 (Registered Nurse/RN) showed at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-19 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to employ a qualified Food Service Director. This applies to all 67 residents in the facility. The findings include: The Centers for Medicaid and Medicare Services Conditions and Census report (CMS-672) dated 7/17/23 showed a census of 67 residents. On 7/19/23 at 8:19 AM, V10 (Food Service Director) said he has not completed the Certified Dietary Manager course and he is not currently enrolled to his knowledge. Facility provided employee file shows V10 was hired on 3/6/23. Facility Dining Services Director job description (no date) states, . Must hold state and/or federal required credential within no more than three months of placement in Dining Services Director/Account Manager position.
- Potential for harm · Fcited before2023-07-19 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to serve the menu as written. This applies to all 67 residents in the facility. The findings include: The Centers for Medicaid and Medicare Services Conditions and Census report (CMS-672) dated 7/17/23 showed a census of 67 residents. Facility provided menu printed on 7/17/23 at 2:32 PM, shows lunch for Monday, 7/17/23 included a turkey and cheese hoagie sandwich, a lettuce and tomato plate, a marinated cucumber and tomato salad, macaroni salad, and a summer fresh fruit cup. On 7/17/23 at 12:45 PM, V12 (Cook) served plain pasta with a turkey and cheese hoagie. On 7/17/23 at 1:58 PM, V11 (District Manager for Healthcare Services Group) said that over halfway through meal service, V11 put Italian dressing onto remaining noodles. On 7/18/23 at 8:29 AM, R45 said the menus don't usually match what we get. On 7/18/23 at 9:14 AM, V10 (Food Service Director) said that the cooks should follow the menu and recipes unless authorized by the Food Service Director. V10 also said the macaroni salad recipe does not use Italian…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-19 · 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 record review the facility failed to wash, handle, and store food service utensils in a sanitary manner. This applies to all 67 residents in the facility. The findings include: The Centers for Medicaid and Medicare Services Conditions and Census report (CMS-672) dated 7/17/23 showed a census of 67 residents. 1. On 7/17/23 at 9:18 AM, V12 (Cook) was at the three-compartment sink washing dirty dishes. V12 then went to the dish machine and removed a clean and sanitized sheet pan to place in the drying area. V12 did not wash hands prior to handling the clean and sanitized sheet pan. On 7/17/23 at 9:20 AM, V12 placed a 4-inch hotel pan into the dish machine. At 9:22 AM, V12 removed the 4-inch hotel pan from the dish machine and placed it in the drying area. V12 did not wash hands prior to handling the clean and sanitized 4-inch hotel pan. On 7/17/23 at 9:27 AM, V12 said hands should be washed between handling dirty and clean dishes. On 7/18/23 at 9:14 AM, V10 (Food Service Director) said employees should definitely wash hands between clean and dirty.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-19 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions were implemented and failed to develop Enhanced Barrier Precautions Policy and Procedures. The findings include: The facility's Resident Census and Conditions Report (CMS) dated 7/17/23 show there were 67 residents residing at the facility. This report also shows that there are 9 residents with indwelling catheters, 8 residents with pressure ulcers, 2 residents receiving tube feedings and one resident receiving Intravenous Therapy. None of these residents were placed on Enhance Barrier Precautions. On 7/18/23 at 10:00 AM, both V2 (Director of Nursing-DON) and V3 (ADON-Infection Control) said they have not implemented the Enhance Barrier Precautions (EBP) at the facility. V2 stated, I heard about that- Enhanced Barrier Precautions, it is a precaution more that the standard precaution, like wearing PPE of gown and gloves for residents with catheters or with wounds. V2 (DON) said they have not updated their Infection Control Policy to include the EBP. The CDC's Implementation 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 · E2023-07-19 · tag F0800 — patternProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
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 use the correct serving utensils for mechanical soft and puree residents. This applies to 14 of 14 residents (R2, R8, R10, R11, R15, R22, R23, R25, R29, R32, R41, R47, R51, and R55) reviewed for mechanically altered diets in the sample of 17. The findings include: Facility provided menu printed on 7/17/23 at 2:32 PM, shows lunch for Monday, 7/17/23, included a turkey and cheese hoagie sandwich, a lettuce and tomato plate, a marinated cucumber and tomato salad, macaroni salad, and a summer fresh fruit cup. Facility provided Order Search reports dated 7/15/23, show R2, R8, R10, R11, R15, R22, R23, R25, R29, R32, R41, R47, R51, and R55 have current orders for mechanically altered diets. Facility provided puree meal ticket dated 7/17/23, shows a #8 scoop (4 ounces) is needed for the pureed turkey, a #16 (2 ounces) scoop is needed for the pureed bread/hot dog bun, a #8 (4 ounces) scoop is needed for the pureed macaroni salad, and a #10 (3 ounces) scoop is needed for the pureed marinated mixed vegetable salad.…
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 · D2023-07-19 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident rooms were maintained in a homelike environment for 2 of 17 residents (R28 and R48) reviewed for homelike environment in the sample of 17. The findings include: On 07/17/23 at 11:12AM, R28's and R48's rooms had loose wallpaper on the wall. The baseboard was loose. The back of the wallpaper had a black substance. The wall under the wallpaper was broken and uneven. There was a dark brown stain at the base of wall and on the floor. On 07/17/23 at 11:12AM, R28 said, look behind the door. They have a shower on the other side of the wall next to my room. I hear things about black mold. I think they could do something about the condition of the wall. It looks bad to me, there is obviously a water leak. Do you see the baseboard, it is swelling up under my closet. Is that from black mold? On 07/17/23 at 1:39PM, R48 said, the wall in my room has been that way since August of 2022 when I was admitted to the facility. On 07/19/23 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 before2023-07-19 · 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 administer prescribed medications and failed to ensure medications were not left at bedside to 2 of 5 residents (R7, R116) in the sample of 17. 1. R116's Physician Order Sheet dated 7/2023 show R116 has an order of Sodium Bicarbonate Oral Tablet 650 mg (milligrams) BID (two times per day) for gastroesophageal reflux disease. On [DATE] at 8:30 AM, R116 was sitting in his room, R116 said he does not get all his medications and his daughter was handling this. On [DATE] at 1:17 PM, V7 (R116's daughter) said R116 was admitted to the facility with orders of Sodium Bicarbonate. V7 said R116 has been on this medication for a long time. V7 said R116 did not get this medication for at least two days. R116's progress notes dated [DATE] timed at 11:26 PM show, Sodium Bicarbonate is not available in the facility. Spoke with NP (Nursed Practitioner) . if there is an alternative medication that we can give, she said to call pharmacy. Pharmacy is closed 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 · F2022-08-24 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 there was adequate staffing in the kitchen. This failure has the potential to effect all 68 residents receiving food from the kitchen. The findings include: The CMS 672- Resident Census and Condition of Residents form completed during the survey shows the census on 8/22/22 was 70 residents and 2 residents are being feed by tube feeding. On 8/22/22 the kitchen was observed continuously from 11:20 AM until 1:45 PM. There were a total of 4 dietary personnel in the kitchen. 3 staff (V9 Dietary Manager, V10 [NAME] and V20 Cook/Aide) who were working the serving prep and service line and 1 staff (V19 PM shift Dishwasher) who came in at 10:00 AM was doing dishes. At 11:30 AM, V9 began making pureed lunch trays. She then continued taking food out of the ovens and placing them on the serving line. V10 and V20 were doing other prep work and getting the serving line ready for the noon meal. Residents began arriving in the dining area at approximately 12:15 PM. At 12:25 PM, V9 began to plate food for residents in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-08-24 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 food was served at a palatable temperature. This failure has the potential to affect all 68 residents receiving food from the kitchen. The findings include: The CMS 672- Resident Census and Condition of Residents form completed during the survey shows the census on 8/22/22 was 70 residents and 2 residents are being feed by tube feeding. On 8/22/22 at 9:09 AM, R54 said the food at the facility is terrible, it is always served late and cold. At 2:15 PM, R54 said his lunch was delivered to him and it was lukewarm. On 8/22/22 at 9:30 AM, R11 said the food is always cold and late. On 8/22/22 at 10:15 AM, R60 said the food is always served to her cold and she had to wait this morning to get brown sugar to put in her oatmeal. On 8/22/22 at 2:16 PM, R7 said staff do not cover hot foods when they bring them to her, and her soup and coffee are always brought in cold. On 8/23/22 a test tray was requested from the kitchen to be sent on the food cart with resident trays. The test tray came at 9:30 AM. The biscuits…
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 · E2022-08-24 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure meals were served according to normal mealtimes in the community. This applies to 4 of 18 residents (R7, R11, R54, R60) reviewed for mealtimes in the sample of 18. The findings include: On August 22, 2022, at 9:30 AM, residents on the 100 hall were being served the morning meal. At 2:14 PM, residents on the 100 hall were being served the noon meal. On August 23, 2022, at 9:20 AM, residents on the 100 hall were being served the morning meal. On August 22, 2022, during the survey R7, R11, R54, & R60 all stated, the meal trays are late every day. On August 22, 2022, at 2:13 PM (prior to meal trays coming) V4 Certified Nursing Assistant (CNA) stated, the meal trays are always late. To be honest, they are this late every day. The facility's grievance report from R26 dated July 19, 2022, shows, Food always late. The facility's grievance report from R60 dated July 25, 2022, shows, No food provided for R60 at 6:30 PM . We did not get dinner until 7:15 PM . The facility's mealtimes list provided shows, Breakfast…
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 before2022-08-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was treated in a dignified manner by all staff. This applies to 1 of 18 residents (R7) reviewed for dignity in a sample of 18. The findings include: On 8/22/22 at 10:15 AM R7 stated, I had an issue with one CNA (V12), and I reported it to the nurse and told him I didn't want her to work with me ever again. R7 stated, I told her that I am paying privately to be cared for at the facility and (V12) told me that I should be thankful that she is taking care of me, then she walked out and slammed the door. R7 stated that she also came in here to answer my call light and said, 'What you want, Boo?' I don't know if that was some kind of slang against me because I am white or what that was, but I told her she should not be talking to me like that. On 8/24/22 at 11:30 AM R7 stated, I don't want to get anyone in trouble, but I reported it to the nurse that was on that night (about 3 weeks ago). I told him I didn't want her working with me again.…
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 before2022-08-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to ensure a suprapubic catheter was changed for a resident with a history of a urinary tract infection for 1 of 7 residents (R42) reviewed for catheter care in the sample of 18. The findings include: On 8/22/22 at 9:05 AM, R42 was sitting in a wheelchair. R42's suprapubic catheter tubing was visible under R42's wheelchair. R42's care plan showed R42 had a history of a urinary tract infection and R42's suprapubic catheter was to be changed every four weeks starting on 8/15/22. R42's Order Summary Report printed on 8/22/22 showed, Per hospital: change suprapubic catheter every 4 weeks at facility beginning on 8/15/22 . for prevention of [urinary tract infections]. On 08/22/22 at 01:16 PM, V2 (Director of Nursing) said if R42's catheter was changed it would have been documented on the Medication Administration Record (MAR). R42's MAR was blank for changing the suprapubic catheter on 8/15/22. On 08/22/22 at 02:11 PM, V2 confirmed R42's suprapubic catheter was not changed on 8/15/22.
- Potential for harm · Dcited before2022-08-24 · 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 ensure a dietitian's recommendations were reviewed with a physician for residents with significant weight loss, failed to notify a dietitian of significant weight loss and failed to implement the dietitian's recommendations for a resident with significant weight loss. This applies to 2 of 6 residents (R39 and R51) reviewed for weight loss in the sample of 18. The findings include: 1. R39's electronic medical records (EMRs) lists her diagnoses to include: dysphagia, diabetes mellitus, dementia, hemiplegia, chronic atrial fibrillation, seizures, history of transient ischemic attack and cerebral infarction without residual deficits and gastro-esophageal reflux disease. R39's EMRs show, her weight on July 1, 2022, as 180.0 lbs (pounds) and her weight on August 1, 2022 as 166.0 lbs. That is a 14 lbs difference and 7.78% weight loss in one month. R39's EMRs does not show that her physician or dietitian was notified of the significant weight loss…
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 · D2022-08-24 · 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 observation, interview and record review the facility failed to administer medications as ordered. There were 26 opportunities with 3 errors resulting in an 11.54 % error rate. This applies to 2 of 3 residents (R24 and R116) observed during medication pass. The findings include: 1. On August 22, 2022 at 9:10 AM, V3 Assistant Director of Nursing (ADON) was passing R24's morning medication. V3 gave R24 1 tablet of R24's Zoloft (anti-depressant) medication with her other morning medications. V3 verified that there were 7 pills in the medication cup. (Should have been 8 pills in total). R24's medication administration record (MAR) for the month of August 2022 shows, Zoloft tablet 50 mg (milligram), give 1.5 tablet by mouth in the morning for depression, Dose = 75 mg. On August 22, 2022 at 1:42 PM, V22 Registered Nurse (RN) verified that R24 has 2 cards for her Zoloft medication. One card is a whole tablet and the other is a 1/2 tablet. R24 is supposed to get 1 full tablet and one 1/2 tablet with her morning medications. V3 only gave 1 tablet. 2. On 8/23/22 at 8:21 AM V17 (LPN-…
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 before2022-08-24 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 ensure food was prepared in a sanitary manner to prevent cross contamination for 1 of 18 residents (R8) reviewed for food preparation in the sample of 18. The findings include: On 8/22/22 at 12:52 PM, V20 (Cook/Aide) picked up a metal spatula that had food debris on it and used it to scrape dried food off of the flat top grill. Without washing the spatula off, he then used that spatula to make a grilled cheese sandwich. V20 had touched items in the kitchen such as the spatula handle, and without changing gloves or using a utensil he then picked up bacon he was cooking on the flat top grill and placed it on the grilled cheese sandwich that was served to (R8). On 8/23/22 at 10:10 AM, V9 (Dietary Manager) said V20 should have used the metal scraper provided to them to clean off the stove not the spatula, and he should have either changed his gloves first or used a utensil to pick up the bacon. The facility provided policy titles Food: Preparation states, All staff will practice proper handwashing techniques 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.
“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
$130,776 in federal fines across 4 penalties. 1 Medicare payment denial on record.
- $83,990 — penalty dated 2026-05-06
- $15,935 — penalty dated 2026-04-20
- $16,801 — penalty dated 2024-11-14
- $14,050 — penalty dated 2024-06-05
- Medicare payment denial — starting 2024-07-05 for 31 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 TUTERA SENIOR LIVING & HEALTH CARE — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 1 of 5 | 1.7 | -0.7 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 24 homes this chain runs (chain average 2.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| JCT INVESTMENTS, LLC | Organization | DIRECT OWNERSHIP INTEREST | since 12/28/2021 |
| TUTERA INVESTMENTS, LLC | Organization | DIRECT OWNERSHIP INTEREST | since 12/28/2021 |
| JOSEPH CHARLES TUTERA 2013 FAMILY IRREVOCIABLE TRUST AGREEMENT | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2023 |
| MARIAN OLANDER TUTERA 2020 MRTL TR | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2023 |
| TUTERA, JOSEPH | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/28/2021 |
| TUTERA, MARIAN | Individual | INDIRECT OWNERSHIP INTEREST | since 12/31/2023 |
| BLOOM, RANDALL | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/28/2021 |
| BROOKS, KILEY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/28/2021 |
| WALNUT CREEK MANAGEMENT COMPANY LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2017 |
| ELMAHBOUB, ASIM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| MORTON, SCOTT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| FLANAGAN, MICHAEL | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 05/21/2025 |
| TI-CRYSTAL LAKE, LLC | Organization | ADP OF THE SNF | since 12/28/2021 |
| FRAASE, JENNIFER | Individual | ADP OF THE SNF | since 05/01/2025 |
CMS files one row per role, so the 23 rows in the source record cover these 14 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.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 17% 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 145257. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-05, 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.