Bethany Rehab & Hcc
3298 Resource Parkway, Dekalb, IL 60115 · For profit - Corporation · 90 certified beds · (815) 756-5526 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Mar 2025
- 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
- inspectors cited 5 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (70) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $407,176 in federal fines (most recent 2025-08-26)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (72%) runs well above the national median (45%)
- 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 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 | 3 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 | 24.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 13.1% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.1% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 28.7% | 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 | 3.6% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 32.7% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.9% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 75.8% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.4% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 29.0% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.0% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 59.8% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.5% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.4% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.53 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.71 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
50.7% 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 180 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.6% 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 71 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 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% 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 | 50.7%CMS range 42.0–58.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 8.0–14.5 | 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 | 60.6% | 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 | 64.8% | 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 | 50.7% | 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 | 94.0% | 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 | 93.3% | 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 | 86.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.7%CMS range 5.8–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 90 beds and averages 68.9 residents a day — about 77% occupied, or roughly 21 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.21 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.21 hrs/resident/day on weekends vs 3.82 on weekdays — 16% thinner on weekends. RN hours go from 1.26 to 1.07 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 72% is well above the national median of 45%. 1 administrator has left in the past year.
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.
70 citations, most serious first. The 24 most serious are shown; the remaining 46 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-06-22 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to notify the physician of R2's critical low blood glucose for a resident with history of critical glucose levels and recent diabetic medication changes for 1 of 13 residents (R2) reviewed for physician notification in the sample of 13. This failure resulted in R2 being found with a critical low blood glucose then R2's heart stopping.The Immediate Jeopardy began on (05/09/2026) when R2's critical low blood sugar was not reported to the physician. V1 Administrator was notified of the Immediate Jeopardy on 06/17/2026 at 3:38PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 06/17/2026 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:R2's Physician Orders dated 05/08/2026 shows, call physician if Blood Sugar is less than 70 milligrams per deciliter or greater than 401 milligrams per deciliter.R2's Vital Sign record dated 05/09/2026 at 7:43AM, shows R2's Blood…
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.
- Immediate jeopardy · Jcited before2026-06-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor a resident's blood glucose levels for a resident with history of critical blood glucose levels and recent diabetic medication changes for 1 of 13 residents (R2) reviewed for Quality of Care in the sample of 13. This failure resulted in R2's blood sugar becoming critically low then R2's heart stopped.The Immediate Jeopardy began on ([DATE]) when R2's critical low blood sugar was not reported to the physician; the facility failed to develop a treatment plan with R2's physician for the critical low blood sugar. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 3:38PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE]. Non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:Normal fasting Blood Glucose/sugar level is 70mg/dl milligrams per deciliter to 100mg/dl…
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.
- Immediate jeopardy · Jcited before2025-02-07 · tag F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 staff failed to provide Cardiopulmonary Resuscitation (CPR) to a resident that was a full code. Failed to recognize the resident's code status, and failed to immediately perform life-saving interventions once the resident's code status was identified, for 1 of 3 residents (R1) reviewed for advanced directives in the sample of 3. No CPR was provided to R1 until after emergency medical services arrived at R1's bedside. This failure resulted in R1 experiencing a delay in life-saving medical care and subsequent death. The Immediate Jeopardy began on 1/26/25 at 5:35 PM when V4 (Licensed Practical Nurse-Agency staff) was informed by V10 (R1's visitor) that R1 was not breathing. V1 (Administrator) was notified of the Immediate Jeopardy on 2/6/25 at 1:17 PM. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 2/7/25, but noncompliance remains at a Level Two because additional time is needed to evaluate 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.
- Immediate jeopardy · Jcited before2025-02-07 · 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 staff provided feeding assistance and supervision for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. This failure resulted in R1 aspirating, becoming unresponsive, and expiring in the facility on 1/26/25. The Immediate Jeopardy began on 1/26/25 at 5:00 PM when V7 took R1's dinner tray into her room and left it on the bedside table for R1's family to feed her. V1 (Administrator) was notified of the Immediate Jeopardy on 2/6/25 at 1:17 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 2/7/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1 was no longer in the facility. R1 expired in the facility on 1/26/25. On 2/4/25 at 12:54 PM, V4 (Licensed Practical Nurse-LPN/Agency Nurse) stated he was standing by his medication cart right…
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.
- Immediate jeopardy · Kcited before2023-09-20 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have staff on duty trained in the use of emergency medical equipment. The facility failed to ensure their policy was followed to use the AED (Automated External Defibrillator) during CPR (Cardiopulmonary Resuscitation). This failure resulted in R1 expiring at the facility. This applies to 24 of 24 (R1, R3-R24) residents in the sample of 24 reviewed for emergency care/CPR. The immediate jeopardy began on [DATE] at 2:22 AM when R1 was pronounced expired after having a sudden cardiac arrest, the staff in facility were unsure of the policy of what to do, how to provide CPR, and did not use the available AED (Automated External Defibrillator). The immediate jeopardy was identified on [DATE]. V1 Administrator was notified of the immediate jeopardy on [DATE]. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on [DATE], but noncompliance remains at a level 2 because additional time is needed…
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 before2026-05-22 · 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 identify pressure ulcers prior to an advanced stage, failed to accurately assess the pressure ulcers and failed to put interventions in place to prevent further skin breakdown for two residents R1 and R3. These failures resulted in R1 developing an unstageable pressure injury to her sacrum on 3/19/26 and R3 developing a pressure injury containing slough (devitalized tissue) to his sacrum on 5/9/26.The findings include: 1.R1's Physician's Order Sheet dated May 2026 shows that she was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Type 2 Diabetes Mellitus, Mild Cognitive Impairment and Dependence on Renal Dialysis. R1's Skin assessment dated [DATE] shows new skin Issue. Location: Sacrum. Issue type: Moisture associated skin damage (MASD). Progress: New: new wound. MASD: IAD Incontinence Associated Dermatitis. Wound acquired in-house. It is unknown how long the wound has been present. Length 5.7 Width 3.83 (cm)…
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 before2025-09-05 · 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 observations, interview, and record review the facility failed to obtain daily weights for a congestive heart failure resident (R52). This failure resulted in R52 gaining 60 pounds in one month and requiring hospitalization. The facility also failed to ensure follow-up care was completed after a resident fell (R60).This applies to 2 of 5 residents (R52, R60) reviewed for quality of care in the sample of 48. Findings Include: 1.On 9/2/25 at 10:22 AM, R52 was seated in a bariatric wheelchair with oxygen in place at 4 liters per nasal canula. R52 was able to speak, but did get short of breath during the interview. R52 stated, “I'm sick of this fluid. I've gained over 43 pounds, and it just seems to keep going up.” R52 said the facility does weigh her, but she doesn't think it's every day. R52 said she has been seen in the past by Cardiology for issues with fluid retention. R52 was obese and had generalized edema noted. R52 said she was on a “water pill” and the facility had added another recently. At 12:30 PM, R52 was seated in her wheelchair in the dining room, feeding…
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 before2025-03-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dressing changes and wound assessments were completed as ordered, failed to ensure a dressing was in place, and failed to identify a wound prior to it becoming an advanced stage for 2 of 3 residents (R1, R5) reviewed for wounds in the sample of 8. This failure resulted in R1 being sent to a local hospital and admitted to the hospital with a diagnosis of wound infections to his bilateral lower extremities. The findings include: 1. R1's admission Record, provided by the facility on 3/25/2025, showed he had diagnoses including, but not limited to, end stage renal disease, stage 5, dependence on renal dialysis, type II diabetes mellitus with diabetic neuropathy (a type of nerve damage that can occur with diabetes causing pain or numbness in the legs or feet), chronic diastolic heart failure, atherosclerotic heart disease, pain in right thigh, pain in right hip, anemia, primary generalized osteoarthritis, chronic peripheral venous…
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 before2025-01-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was transferred safely with a gait belt for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a distal femur fracture. The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including a history of falls and weakness. The 12/18/24 facility incident report documents the CNA (certified nursing assistant) was transferring a resident (R1) from a wheelchair to a bed using a gait belt. During the transfer, the resident's knees gave out, and the CNA lowered the resident to the floor. The same report notes R1 to be alert and oriented. R1's admission assessment and care screening of 12/22/24 showed her to be cognitively intact, risk for falls and had impairment to both of her lower extremities. The same assessment documents she required maximal assist for mobility including sit to stand/hoyer for transfers related 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.
- Actual harm · Gcited before2024-09-24 · 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 observation, interview and record review, the facility failed to ensure the theft of a resident's charge card and debit card did not occur for 1 of 3 residents (R1) reviewed for theft in the sample of 9. This failure resulted in R1 being very distraught, crying, and needing to be consoled by facility staff. The findings include: R1's admission Record, provided by the facility on 9/24/24, showed she was admitted to the facility on [DATE]. R1's facility assessment dated [DATE], showed she was cognitively intact, with no hallucinations, delusions, or behaviors. The assessment showed R1 had limitations to her range of motion on her bilateral upper and lower extremities. The assessment showed R1 required substantial/maximal assistance from staff for toileting and lower body dressing, and partial/moderate assistance from staff for upper body dressing, bed mobility, and transferring from her bed to her wheelchair and back to bed. The assessment showed R1 did not ambulate during the look-back period of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-07-24 · 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 identify, assess, and treat a resident's pressure injuries before becoming unstageable and Stage 3, failed to ensure pressure prevention interventions were in place, and failed to do weekly skin assessments for 4 of 6 residents (R51, R224, R3, R62) reviewed for pressure injuries in the sample of 17. This failure resulted in R51 developing an unstageable pressure injury to his left heel, a stage 2 pressure injury to his right heel and a Stage 3 pressure injury to his right scapula and R224 developing a Stage 3 pressure injury to her coccyx. The findings include: 1. On 07/22/24 at 12:18 PM, R51 was in bed that was low to the floor with fall mats on both sides of bed. R51's heels were flat on the bed and there were heel boots sitting in the chair at the bedside. On 07/24/24 at 9:37 AM, V8 Wound Nurse stated heel boots are for wound healing and prevention. R51 had heel boots for prevention and now for healing. V8 stated R51 did not have wounds when he was admitted here. V8 stated the nurse informed her of R51's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-07-24 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents pain medications were administered for 2 of 17 residents (R223, R67) reviewed for pain in the sample of 17. This failure resulted in R223 suffering with pain due to metastatic breast cancer with lesions to the bone and liver. The findings include: 1. On 07/22/24 at 9:16 AM, R223 was in bed watching TV. R223's face and arms were yellow in color. When asked how everything was going, R223's face appeared sad, and R223 stated It was a horrible start since admission. I felt rushed being discharged from the hospital, they weren't even ready for me here. They didn't have my medications. I got here Thursday night (7/18/24) and they didn't' have my pain medications until Saturday morning (7/20/24). The pain by that time was and 8 out of 10. I was so uncomfortable and upset, why not wait for discharge so all my medications can be ready? R223's Face sheet shows R223 was admitted to the facility on [DATE]. R223's Hospital History 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.
- Actual harm · Gcited before2024-05-28 · 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 thoroughly assess a resident's malfunctioning catheter. This failure resulted in the resident (R3) experiencing bleeding, catheter pain and needing to be admitted to the local hospital. The facility also failed to prevent a suprapubic catheter from being displaced during care. This applies to 2 of 3 residents (R3 and R1) reviewed for catheters in the sample of 4. The findings include: 1. On 5/28/2024 at 12:50PM, R3 stated staff tried to put a catheter in and wasn't sure what happened. R3 stated his p started bleeding and wouldn't stop. R3 stated blood was all over the place. R3 stated he was sent to the hospital and ended up in the intensive care unit. On 5/28/2024 at 1:25PM, V7 Licensed Practical Nurse (LPN) stated she was caring for [R3] on 5/20/2024 during the day shift (7:00AM - 3:00PM). V7 said between 1:00PM - 2:00PM [R3] said this damn thing is hurting referring to his p. V7 said [R3] told her the tip of his p 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.
- Actual harm · Gcited before2023-06-29 · 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 observation, interview, and record review the facility failed to identify pressure injuries prior to becoming unstageable, as a result of this failure R8 developed multiple pressure injuries to her heels. The facility also failed to ensure current wound treatments were completed, failed to ensure pressure ulcer prevention measures were in place and failed to clean a pressure wound in a manner to prevent cross contamination for 2 of 3 residents (R34, R51) reviewed for pressure injuries in the sample of 17. The findings include: 1. R8's admission Record shows she was admitted to the facility on [DATE]. The June 2023 POS (physician order summary) shows an order to float heels while in bed every shift for prevention of skin breakdown. The orders include skin prep daily and as needed for wound care to the right heel and the left heel starting 6/23/23. The 4/18/23 Facility admission Assessment documents R8 to have severe cognitive impairment. The same assessment shows she is dependent on staff for bed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-22 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to report an allegation of abuse for 1 of 18 residents (R1) reviewed for abuse in the sample of 18.The findings include: On 06/15/2026 at 12:30PM, R1 was sitting on the side of the bed with an incontinent brief and strong odor of urine.On 06/15/2026 at 12:30PM, R1 said, the staff do not answer lights. The staff have talked mean to me in the past. I do not know their names; they have no name tags.On 06/16/2026 at 12:30PM, V5 Housekeeping said, R1 was in the bathroom with the call light on. V9 CNA was in another resident's room with the other CNA. I told V9 CNA one of the residents needed help. V9 CNA asked if it was the small one or the fat one. I said, the larger person. Both CNAs laughed, I walked away. I did not need to report the incident. R1's nurse overheard what V9 CNA was saying. The nurse confronted V9. The nurse was going to report V9's actions. Then V9 got loud and started cursing at the nurse. I do not remember who the nurse is. On 06/16/2025 at 12:46PM, V1 Administrator said, I do not know the nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 honor resident's preference to be up for breakfast for 1 of 3 residents (R2) reviewed for resident's rights in the sample of 6.The findings include:R2's facility assessment dated [DATE] shows she has no cognitive impairment-BIMS (Brief Interview for Mental Status) of 15.On 5/1/26 at 9:00 AM, R2 was in bed waiting to get up. R2 was very upset. R2 said this was the 4th time she was not up for breakfast. R2 stated she has been a resident in this facility for four years and that staff are all familiar with her daily schedule. R2 said it was her preference to be up by 6:30 AM to eat breakfast in the main dining room. R2 said staff should respect her preference. R2 said the staff that have been taking care of her lately seemed not to know her established routine.On 5/1/26 at 9:05 AM, V7 (Certified Nursing Assistant-CNA) said she was just pulled to replace R2's assigned CNA that did not show up this morning and got R2 as her resident just now.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-01 · 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 observation, interview, and record review, the facility failed to ensure resident's safety during a wheelchair transport for 1 of 3 residents (R1) reviewed for safety in the sample of 6.The findings include:The Facility Reported Incident (FRI) sent to state agency with incident date of 4/5/26 (date of report as 4/6/26) shows, R1, fell when she abruptly stood up while staff were transporting her, R1 sustained laceration to forehead. R1 was sent to ED (emergency department) via ambulance for treatment and evaluation. A thorough investigation has been completed. R1, who is with impaired balance and unsteady gait requires assistance with all transfers. R1 returned to facility after the evaluation with negative x-rays and adhesive used for forehead laceration. Staff statements show R1 suddenly stood up and fell. R1's wheelchair did not have foot pedals. Fall interventions are in place and include using foot pedals on wheelchair when transporting the residents.R1's ED note dated 4/5/26 shows fall on the same level from slipping, tripping or stumbling. Cut on forehead (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.
- Potential for harm · Dcited before2026-04-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received a shower/bath at least twice a week for 1 of 3 (R1) residents reviewed for activities of daily living (ADLs) in the sample of 5.The findings include:On 3/31/26 at 8:48 AM, R1 was lying flat in bed on a low air loss mattress. R1 said her last shower was six to seven weeks ago. R1 said they don't offer to shower her, but staff mentioned giving her a shower yesterday and didn't do it. R1 said staff later mentioned giving her a bed bath but didn't do it either. R1's hair appeared greasy, and she had dry, flaky skin on her feet.On 3/31/26 at 9:40 AM, V6, (Certified Nursing Assistant-CNA), said residents are to be showered at least twice a week.On 3/31/26 at 9:47 AM, V8, (CNA), said showers are given at least twice a week to each resident. V8 said there is a shower schedule in the shower book at the nurse's station. V8 provided the book and showed the schedule. V8 said they chart the resident showers in the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure routine dental care was provided and failed to provide transportation to an oral surgery procedure for 2 of 3 residents (R1 and R2) reviewed for dental care in the sample of 5.The findings include:1.On 3/31/26 at 8:48 AM, R1 said she needs to see an oral surgeon because a tooth needs to be pulled. R1's teeth appeared to be in poor condition. On 3/31/26 at 10:30 AM, V1, Administrator, said she spoke to R1's sister, V10, about R1's teeth. V1 said R1 needs to see an oral surgeon.R1's Progress Notes dated 4/10/26 at 11:46 AM shows R1 is set up for tooth extraction on 4/15/26 at the hospital with V11, oral surgeon. R1's primary care provider was made aware R1 needed medical clearance for the procedure and planned to see R1 on 4/11/26. R1's Progress Notes dated 4/11/26 at 9:21 AM shows staff left a voicemail informing V10 about R1's tooth extraction appointment on 5/15/26. A request for transportation was left with the former Transformation…
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 before2026-03-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a gait belt was used for a resident during a transfer for 1 of 7 residents (R1) reviewed for quality of care/safety in the sample of 7.The findings include:The Grievance Form dated 2/10/26 for R1 showed R1 was upset that the certified nursing assistants (CNA) on third shift lifted her up by her arms instead of using a gait belt. R1 did not have any injuries. On 3/10/26 at 2:30 PM, V4 (Physical Therapy Assistant) stated when a resident is a one person or two person assist a gait belt should be used. V4 stated it was important for the gait belt to be used because the resident could lose their balance; it is for safety. On 3/10/26 at 3:40 PM, V1 (Administrator) stated a third shift CNA did not use a gait belt when transferring R1. The CNA held R1 up under her arms. V1 stated R1 reported it and she went to talk to her. V1 stated the CNA should have used the gait belt for the safety of the resident and themselves.The Care Plan dated 12/24/25 for R1 showed she has an activity of daily living self care deficit related 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 · Ecited before2026-02-24 · 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 observation, interview, and record review, the facility failed to provide medications as ordered for five of ten residents (R1, R2, R4, R5, R9) reviewed for medications in the sample of ten.The findings include:1.R1 was admitted to the facility on [DATE], with diagnoses including epilepsy, weakness, morbid obesity, contracture of left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis. R1's Medication Administration Record (MAR) dated February 1, 2026-February 28, 2026 shows orders for buspirone tablet 15 mg (milligrams) two times a day related to anxiety disorder scheduled at 9:00 AM and 5:00 PM, carbamazepine extended release tablet 100 mg give three tablets two times a day for antiseizure at 9:00 AM and 5:00 PM and two tablets by mouth at 12:00 PM, and losartan potassium 50 mg by mouth daily for high blood pressure hold if top number in blood pressure < 100. On February 23, 2026, at 11:16 AM, V4 Registered Nurse (RN) took R1's blood…
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 before2026-02-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 Activities of Daily Living (ADL) assistance was provided to residents that required assistance for three of ten residents (R9, R1, R2) reviewed for ADLs in the sample of ten.The findings include:1.R9's admission Record shows she was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, weakness, unsteadiness on feet, dysphagia, anxiety disorder, high blood pressure, heart disease, gastro esophageal reflux disease, and osteoarthritis. R9's Care Plan shows R9 has an ADL self-care performance deficit. R9 requires the assistance of one staff member with bathing, personal hygiene, and oral care. R9 has refused to be shaven, if R9 resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time.On February 23, 2026, at 1:17 PM, R9 was sitting in her…
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 · D2026-02-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility to ensure medications were administered and administered at the prescribed time for two of two residents (R5, R4) observed during the medication pass. There were 25 opportunities with 7 errors, resulting in a 28% error rate.The findings include:1.R5's admission Record shows he was admitted to the facility on [DATE], with diagnoses including polycythemia vera (rare chronic blood cancer) osteoarthritis, dysphagia, high blood pressure, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falling.R5's MAR dated February 1, 2026-February 28, 2026, shows orders for cyanocobalamin (a vitamin) 1000 mcg (micrograms) daily at 9:00 AM, hydroxyurea (chemotherapy medication) 500 mg (milligrams) give two capsules by mouth daily at 9:00 AM related to polycythemia vera, metoprolol 25 mg give 1/2 tablet at 9:00 AM and 9:00 PM every morning and bedtime related to high blood…
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 · D2026-02-24 · 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 observation, interview, and record review, the facility failed to ensure significant medication errors did not occur for two of ten residents (R1, R5) reviewed for medications in the sample of ten.The findings include:1.R1 was admitted to the facility on [DATE], with diagnoses including epilepsy, weakness, morbid obesity, contracture of left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis. R1's Medication Administration Record (MAR) dated February 1, 2026-February 28, 2026, shows orders for carbamazepine extended-release tablet 100 mg (milligrams) give three tablets two times a day for antiseizure at 9:00 AM and 5:00 PM and two tablets by mouth at 12:00 PM, and losartan potassium 50 mg by mouth daily for high blood pressure hold if top number in blood pressure < 100. On February 23, 2026, at 11:16 AM, V4 Registered Nurse (RN) took R1's blood pressure. R1's blood pressure was 107/60. R1 complained of nausea, so V4 gave R1 an antinausea…
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 46 citations
- Potential for harm · Dcited before2026-01-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the physician following a fall incident that subsequently resulted in a significant injury and failed to notify physician of a hospital transfer for one of three residents (R1) reviewed for falls in the sample of three. The findings include:R1's face sheet documented admission date of 08/28/2023 with past medical history not limited to left femur fracture, weakness, history of falls, cognitive communication deficit and adjustment disorder with mixed anxiety and depressed mood.R1's fall incident report dated 12/30/2025 at 06:45 PM (1845) indicated that resident had a fall incident in the bathroom. Staff was present at time of fall. Report documented under agencies/people notified that only V2 (Assistant Director of Nursing/ADON) was notified on the same day at 07: 58 PM (1958). Fall report did not document that R1's primary care physician (V4-Medical Doctor/MD) was notified of the fall. Health Status Note dated 12/30/2025 at 07:31 PM (19:31)…
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 before2026-01-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the necessary care and services were given to a resident by not immediately obtaining a diagnostic test (x-ray) following a fall, and failed to ensure there was no delay in evaluation and treatment for a resident following a fall for one of three residents (R1) reviewed for falls in the sample of three. The findings include:R1's face sheet documented admission date of 08/28/2023 with past medical history not limited to left femur fracture, weakness, history of falls, cognitive communication deficit and adjustment disorder with mixed anxiety and depressed mood.R1's fall incident report dated 12/30/2025 at 06:45 PM (1845) indicated that resident had a fall incident in the bathroom and staff was present at time of fall.Health Status Note dated 12/31/2025 at 10:56 AM indicated writer noted a small bruise to R1's left knee and resident complained of pain in left leg and knee. Writer called his primary physician and left an urgent note with medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-05 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to consistently provide sufficient staffing to meet the care needs of its residents. This failure has the potential to affect all 68 residents residing at the facility. Findings Include:On 09/02/2025, V1 (Administrator) provided facility assessment dated [DATE] that documented on page 29 of 52, sufficient nursing staffing: the facility will provide help and care needed without the resident waiting a long time (as perceived). The staff will respond to call lights timely. Resident roster provided by facility and CMS form 802 both dated 09/02/2025, showed an in-house census of 68 residents. Review of nursing schedules and daily work log from 08/2025 through 09/04/2025 provided by facility showed several nursing and/or aide staffing shortages as follows: On 08/01, six aides and one trainee were scheduled for day shift but only five aides worked that shift. On 08/02, four aides were scheduled for third shift but only three aides worked that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-05 · 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 provide the residents with food that is palatable in flavor. This applies to all residents in the facility. Findings Include:The CMS (Centers for Medicare and Medicaid) 671 form dated 9/2/2025 shows there are 68 residents in the facility. The menu for lunch on 9/2/2025 shows a pork and rice casserole was to be served. At 11:40 AM on 9/2/2025, V4 [NAME] was observed adding rice to the pork and rice casserole that was on the steam table. V4 said he needed to use another pan to make enough rice for the casserole. V4 stirred the casserole to combine the new rice added. The temperature was checked the casserole was served to the residents. At 1:00 PM, the rice casserole was tasted by the surveyor, and no flavor could be tasted, the meat was tough to chew, and the rice was clumped and stuck together. There was no color to the dish.On 9/2/2025 at 1:02 PM, V4 said when he made the casserole, he did not have all the ingredients and did not put in the celery and lemon juice. V4 said he tries to add some flavor to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have a system in place to track and trend infections in the facility, failed to have a resident on contact isolation as ordered (R13) and failed to change a residents (R7) wound dressing in a sanitary manner. This applies to all 68 residents in the facility. Findings Include: The CMS (Centers for Medicare and Medicaid) 671 form dated 9/2/2025 shows there are 68 residents in the facility. 1.The facility infection surveillance report for the last 3 months shows a space for the resident name, room number, infection onset, infection, signs & symptoms, status, pharmacy order and comments. The report is not fully complete, missing infection, signs & symptoms, pharmacy orders and comments. On 9/3/2025 at 1:30 PM, V2 ADON (Assistant Director of Nursing) and IP (Infection Preventionist) said the purpose of the report is to be able to track and trend the facilities infections. Currently V2 says she just refers to the residents' records 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 before2025-09-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 dependent residents received scheduled showers for 3 of 5 residents (R41, R3, R28) reviewed for activities of daily living in the sample of 48. Findings Include: 1. R41's face sheet showed she was admitted to the facility 1/27/21 with diagnoses to include weakness, unsteadiness on feet, anxiety disorder, dysphagia, hypomagnesemia, hypotension, and generalized osteoarthritis. R41's September 2025 Physician Order Sheet showed, “Shower days: Wednesday and Friday, day shift.” On 9/2/25 at 4:00 PM, V33 (R41's Power of Attorney) said R41 has been having a really hard time getting her showers. V33 said it will be weeks and weeks between R41 receiving showers. V33 said they have made several complaints to the facility regarding the lack of showers and the facility is well aware that it is an ongoing issue for R41. R41's shower documentation showed from 7/1/25 through 9/4/25, R41 received 3 showers. R41's documentation shows the last shower…
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 · D2025-08-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise and update the comprehensive care plan after an elopement attempt for one resident (R1) at risk for elopement of three residents reviewed for elopement in the sample of three Findings include:Physician Order Summary Report indicates R1 was admitted to the facility 8/30/24 with diagnoses that include Dementia without Behavioral Disturbance, Diabetes Mellitus, Generalized Anxiety Disorder and Encephalopathy.On 8/22/25 and 8/26/25 R1 was in a wheelchair and noted to self-propel the wheelchair with his feet.Behavior Note dated 8/2/25 at 4:03am indicates At approximately 4am (R1) eloped from the facility through the front door. Alarm went off and (R1) was returned to the facility.On 8/22/25 at 1:46pm V6, LPN (Licensed Practical Nurse) stated she was R1's nurse on 8/2/25. V6 stated R1 required redirection all night due to trying to get to the front doors. V6 stated R1 was always in a wheelchair and was mobile by using his feet/legs to self-propel throughout the facility. V6 stated R1 was really quick You would…
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 before2025-08-26 · 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
Based on observation, interview and record review the facility failed to ensure one resident at risk for elopement (R1) had sufficient supervision to prevent elopement, failed to address an elopement attempt and failed to implement interventions after an elopement attempt for once of three reviewed for elopement in the sample of three. Findings include:Physician Order Summary Report indicates R1 was admitted to the facility 8/30/24 with diagnoses that include Dementia without Behavioral Disturbance, Diabetes Mellitus, Generalized Anxiety Disorder and Encephalopathy.On 8/22/25 and 8/26/25 R1 was in a wheelchair and noted to self-propel the wheelchair with his feet.Behavior Note dated 8/2/25 at 4:03am indicates At approximately 4am (R1) eloped from the facility through the front door. Alarm went off and (R1) was returned to the facility.On 8/22/25 at 1:46pm V6, LPN (Licensed Practical Nurse) stated she was R1's nurse on 8/2/25. V6 stated R1 required redirection all night due to trying to get to the front doors. V6 stated R1 was always in a wheelchair and was mobile by using 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 before2025-05-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide incontinence care to a resident who requires assistance with ADLs/Activities of Daily Living. This applies to 1 of 3 residents (R1) in the sample of 5. The findings include: R1's admission Record dated 4/7/2025 lists diagnosis of hemiplegia and weakness. R1's MDS (Minimum Data Set) section C dated 4/7/2025 shows a BIMS (Brief Interview of Mental Status) of 15 cognitively intact. On 5/7/2025 at 8:55AM, R1 said the previous day there were not enough staff that day. R1 said call light wait times were long and he had had a bowel movement around 4:00AM that day. R1 said staff came in at around 9:00AM but he didn't get cleaned up until almost 10:00AM by V4 Certified Nursing Assistant (CNA). On 5/7/2025 at 10:06AM, V4 said she is a CNA but was hired for restorative. V4 said she was working on 5/6/2025. V4 said she starts her shift at 8:00AM until 4:00PM Monday through Friday. V4 said when she came in on 5/6/2025 the staff were behind getting patients up and getting meal trays passed. V4 said she did get [R1] up that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-07 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review the facility failed to provide sufficient staff to meet residents care needs for residents requiring assistance with care. This applies to 3 of 3 (R1, R2, R3) residents reviewed for staffing in the sample of 5. The findings include: R1's admission Record dated 4/7/2025 lists diagnosis of hemiplegia and weakness. R1's MDS (Minimum Data Set) section C dated 4/7/2025 shows a BIMS (Brief Interview of Mental Status) of 15 cognitively intact. On 5/7/2025 at 8:55AM, R1 said the previous day there were not enough staff that day. R1 said call light wait times were long and he had had a bowel movement around 4:00AM that day. R1 said staff came in at around 9:00AM but he didn't get cleaned up until almost 10:00AM by V4 Certified Nursing Assistant (CNA). On 5/7/2025 at 10:06AM, V4 said she is a CNA but was hired for restorative. V4 said for the last couple of weeks she has been pulled to the floor or to help in the kitchen doing tickets because they have needed help. V4 said she was working on 5/6/2025. V4 said she starts her shift at 8:00AM until 4:00PM…
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 before2025-03-28 · 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, record review the facility failed to label foods after they were prepared for residents. This has the potential to affect all 77 residents residing in the facility reviewed for food safety requirements. The findings include: The facility data sheet dated 3/25/2025 shows a resident total census of 77. On 3/25/2025 at 8:11 AM, observations of the refrigerator, bread rack, and dry good storage area were made. The bread rack had 8 shelves of bread that were undated but did not have any mold or discoloration noted on them. Multiple containers of food were found to be undated in the refrigerator. A brown sack lunch was sitting on the shelf undated as well. On 3/25/2025 at 8:11 AM, V4 (Cook) identified containers of cream of wheat, tomato sauce, and chicken noodle soup, which were not in their original containers with no opened date or expiration date listed inside of the refrigerator. V4 said all the bread came in on the truck yesterday and should have been labeled upon arrival. V4 said the containers of food in the refrigerator should be labeled with an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-28 · 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 was free from abuse for 1 of 8 residents (R1) reviewed for abuse in the sample of 8. The findings include: R1's admission Record, provided by the facility on 3/25/2025, showed he had diagnoses including, but not limited to, end stage renal disease, stage 5, dependence on renal dialysis, type II diabetes mellitus with diabetic neuropathy, chronic diastolic heart failure, atherosclerotic heart disease, pain in right thigh, pain in right hip, anemia, unspecified dementia-unspecified severity, with other behavioral disturbance, primary generalized osteoarthritis, chronic peripheral venous insufficiency, lumbago with sciatica, peripheral vascular disease, chronic pain, and muscle spasm of back. R1's facility assessment dated [DATE] showed he was cognitively intact, requires substantial/maximal staff assistance for upper body dressing, and partial/moderate staff assistance for lower body dressing. R8's (R1's roommate) admission Record,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure ulcer assessments were performed, failed to ensure wound treatments were performed, and failed to implement pressure relieving interventions for 1 of 3 residents (R2) reviewed for wounds in the sample of 8. The findings include: R2's face sheet printed on 3/25/25 showed diagnoses including but not limited to left side hemiplegia, diabetes mellitus, obesity, and stage 2 pressure ulcer of the sacral region (area between lower back and upper buttock). R2's facility assessment dated [DATE] showed no cognitive impairment and staff assistant required for toileting, transfers, and bed mobility. The same assessment showed R2 is always incontinent of bowel. R2's pressure ulcer risk assessment dated [DATE] showed a high risk for wound development. R2's weight summary report showed a weight of 260 pounds as of 3/24/25. On 3/25/25 at 8:58 AM, R2 was lying in bed while V13 (CNA-Certified Nurse Aide) was assisting with morning cares. R2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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 provided ADL (Activity of Daily Living) care prior to transfer to hospital for (R1) 1 of 3 residents reviewed for ADL care in the sample of 3. The findings include: R1's face sheet printed on 3/17/25 show R1 had diagnoses that include COVID 19 positive, Dementia and Anxiety. R1's facility assessment dated [DATE] under functional ability show R1 is frequently incontinent of bowel and bladder and needs assistance with transfers and toileting. R1's progress note dated 3/12/25 timed at 18:45 (6:45 PM) show R1's oxygen saturation was low (at 85%). R1 was being sent to the hospital for evaluation via 911. R1's hospital record dated 3/12/25 documents- upon arrival to Emergency Department (ED), pt/patient was noted to have soaked brief and her pants/linens underneath her were soaked all the way down to her ankles with odorous urine. On 3/17/25 at 10:38 AM, V4 (License Practical Nurse-LPN) stated on 3/12/25, she was R1's PM shift Nurse. V4…
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 before2024-12-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all doses of a narcotic pain medication was documented on the Individual Resident Controlled Substance Record and the medication administration record as administered for one of three residents (R1) reviewed for narcotic medication administration. Findings include: R1's medical record indicated the resident admitted to the facility on [DATE] with a past medical history not limited to hypertension, congestive heart failure, restless legs syndrome, pain in left leg, low back pain and idiopathic peripheral autonomic neuropathy. Review of R1's current physician orders showed the following medication order: give 1 tablet of hydrocodone-acetaminophen (Norco-a combination opioid and non-opioid pain medication) 5-325 milligram (mg) oral tablet by mouth every 6 hours as needed for pain with an active start date on 2/19/24. Review of R1's Brief Interview for Mental Status assessment dated [DATE] documented a score of 15 which indicated the resident had no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-27 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 equipment was maintained for an emergency supply cart for 52 residents residing on the north hallway. The facility failed to ensure physician ordered daily weights were obtained for 1 of 5 residents (R3) reviewed for quality of care in the sample of 12. The findings include: 1. The 12/27/24 resident list report shows 52 residents reside on the north hallway. On 12/27/24 at 9:00 AM, the north crash cart check list shows a list of items on the emergency cart to be checked daily, including the oxygen tank (full). The last date the list was checked was 12/17/24. On 12/27/24 at 9:40 AM, V7 LPN (Licensed Practical Nurse) stated all items on the list should be checked daily. V7 checked the oxygen tank, and it was empty. V7 stated the cart should have a full tank of oxygen in case there was a code blue, the staff would have to scramble to find a full tank down the hallway, causing a delay in getting oxygen for the resident. On 12/27/24 at 2:00 PM, V2 DON (Director of Nursing) stated the night shift should be…
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 · D2024-12-27 · 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
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 with dignity for 1 of 1 resident (R2) reviewed for dignity in the sample of 12. The findings include: R2's admission record shows she was admitted to the facility on [DATE] following a fall with a facial fracture. The order summary report shows an order to discharge home on [DATE]. The facility's 12/22/24 resident assessment and care screening documents R2 was cognitively intact and required partial/moderate assistance with hygiene and showering/bathing. R2's progress notes for 12/21/24 were reviewed and show V14 LPN (Licensed Practical Nurse) documented R2's family reported they were going to take R2 home if the facility could not provide a shower. V14 documented he asked the day shift aide to give R2 a shower and she refused. V14 noted V2 DON (Director of Nursing) was notified. When family member came back reporting that if their mother does not get a shower they will leave against medical advice. On 12/27/24 at 12:00 PM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-07 · 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 empty a catheter bag before it was full. This applies to 1 of 3 (R2) residents reviewed for catheters in the sample of 6. The findings include: On 11/6/2024 at 9:45AM, R2 in his room sitting up in his wheelchair with a catheter bag resting near the front of his wheelchair. On 11/6/2024 at 9:45AM, R2 stated the urine collection bag for his catheter was full and was uncomfortable. R2 stated he called for assistance using his call light. On 11/6/2024 at 10:38AM, V3 Licensed Practical Nurse (LPN) stated [R2] drinks a lot of water, requiring staff to empty his catheter bag more than once a shift. On 11/6/2024 at 1:13PM, V3 stated she entered [R2's] room and his catheter bag was full. V3 stated she emptied approximately 2000cc on 10/29/2024. On 11/6/2024 at 10:00AM, V2 Director of Nursing (DON) stated foley drainage bags need to be emptied in a timely fashion before it is full. V2 stated catheter bags are emptied at least once a shift or as needed based on patient output. On 11/6/2024 at 3:15PM, V1 Administrator…
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 before2024-11-07 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident with a recent history of pelvic and arm fracture received pain medication as ordered. This applies to 1 of 3 (R1) residents reviewed for pain management in the sample of 6. The findings include: On 11/6/2024 at 9:21AM, R1 stated she was admitted on [DATE] following a hospitalization for a fall at home resulting in surgical intervention and subsequent rehab. R1 stated she sustained pelvic fractures and a left arm fracture during the fall. R1 said she was admitted around 2:00PM on 10/25/2024 and didn't receive her prescribed oxycodone until around 11:00PM. On 11/6/2024 at 2:53PM V4 Licensed Practical Nurse (LPN - agency) stated she worked at the facility on 10/25/2024 from 7:00AM to 11:00PM stated she was aware [R1] had an order for oxycodone. V4 stated she called the pharmacy and requested a stat (right away) refill of the prescription for [R1]. V4 said she didn't have access to the med storage system to pull oxycodone for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-02 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 physician documented, in a resident's medical record, the basis or need for a facility-initiated transfer of a resident. The facility failed to communicate with, verbally or in writing, a local hospital prior to transferring a resident to ensure an effective and safe transition in care. These failures apply to 1 of 3 residents (R1) reviewed for resident transfer/discharge in the sample of 7. The findings include: R1's progress note dated 9/30/24 showed R1 was transferred to a local hospital for an evaluation due to R1's skin tuberculosis (TB) skin test being read as positive/reactive and a recent abnormal chest X-ray result. R1's chest X-ray report dated 9/30/24 showed R1's chest X-ray results as, There are opacities in the right lung base. This may be due to atelectasis or pneumonia. These findings are worse compared with prior. Although these findings are nonspecific, active pulmonary tuberculosis cannot be excluded. R1's electronic medical records dated 9/29/24-10/2/24 showed no physician documentation, notes,…
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 · D2024-10-02 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide a resident or their representative with a bed hold notice prior to transferring a resident to the hospital for 1 of 3 residents (R1) reviewed for bed hold notifications/transfers in the sample of 7. The findings include: R1's progress note dated 9/30/24 showed R1 was transferred to a local hospital for an evaluation due to R1's skin tuberculosis (TB) skin test being read as positive/reactive and a recent abnormal chest X-ray result. R1's electronic medical records dated 9/29/24-10/2/24 showed no documentation R1 or V6 (R1's POA/power of attorney) received a bed hold notice prior to R1 being transferred on 9/30/24. On 10/2/24 at 1:30 PM, V7 Licensed Practical Nurse (LPN) stated she was involved with R1's transfer on 9/30/24. V7 stated, When a resident is transferred, a copy of their advanced directives, emergency contact information, bed hold notification, order summary reports, and change in condition report are to be sent with the resident when transferred. As far as I know, nothing was sent with (R1) when she 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 · Ecited before2024-07-24 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure food was handled in a manner to prevent cross contamination for 4 of 17 residents (R61, R62, R67, R71) reviewed for dietary services in the sample of 17. The findings include: On 7/22/24 at 11:40 AM during plating of the noon meal, V7 (Dietary Aide) was handling diet cards, touching surfaces including the refrigerator handle, outside packages of hamburger buns and other scoops. V7 still wearing the same gloves was then asked by the surveyor what size scoop she was using to serve and plate the cole slaw. V7 replied I am not sure and used her gloved fingers to wipe cole slaw out of inside the scoop in an attempt to read the scoop size marking, V7 then put the scoop back into the cole slaw and continued to plate and serve it to residents. A facility provided resident Diet Report shows R61, R62, R67 and R71 receive regular diets and were served the cole slaw. On 7/23/24 at 11:53 AM, V4 (Dietary Manager) said V7 should not have used her hands to scoop out the cole slaw and touching other objects and 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.
- Potential for harm · Ecited before2024-07-24 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow their Covid-19 policies and procedures for Cohorting Covid-19 positive and Covid-19 negative residents and failed to ensure the required Personal Protective Equipment (PPE) was worn when in rooms of residents on Contact/Droplet isolation for Covid-19. This applies to 6 of 17 residents (R41, R44, R18, R29, R11, R49) reviewed for infection control in the sample of 17. The findings include: 1. On 7/22/24 at 8:00 AM upon entering the main door to the facility there was a sign indicating the facility currently had positive cases of Covid-19. On 7/22/24 at 8:30 AM, during the entrance conference with V1 (Administrator) a resident census list was given to the survey team, and he identified R11 and R49 as being Covid-19 positive and in isolation. The list provided showed R11 and R49 both had roommates (R41 and R29). On 7/23/24 at 10:41 AM, V3 (Assistant Director of Nursing/Infection Preventionist) stated R11 and R49 both tested positive for Covid-19 on 7/20/24, and earlier that morning 2 new residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-24 · 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
Based on observation, interview, and record review the facility failed to ensure a resident was treated with dignity following a room transfer. This applies to 1 of 17 residents (R11) reviewed for dignity in the sample of 17. The findings include: On 7/24/24 at 10:00 AM, R11's call light was on, and Surveyor entered the room with V13 (CNA/certified nursing assistant). R11 was lying in bed. (R11) is currently on isolation precaution due to being positive for COVID. R11's bed was positioned with one side against the wall and the other side open to the middle of the room. R11's nightstand was pressed against the wall, near the head of R11's bed but also behind her as R11's head was slightly elevated. R11's digital clock was plugged into the wall, sitting on the nightstand, the time was not set, and the clock was flashing (2:34). R11 stated, Oh, I love my clock. I need my clock and I can't see it. Do you think you could get me a remote for the television? I can't turn it on. R11's roommate (R49) stated, You have to get one from the maintenance man, there isn't one in here. Resident then…
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 before2024-07-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide activities of daily living (ADL) including incontinence care and showers for 1 of 17 residents (R3) reviewed for ADLs in the sample of 17. The findings include: On 07/22/24 at 10:24 AM, R3 was in bed. V21 and V22 Certified Nursing Assistant (CNA) stated they were going to change R3 and clean her up for the wound nurse to see. V21 and V22 rolled R3 to her right side and R3 had stool halfway down her thigh and up to her middle back. The back of R3's shirt was soaked with urine from her nephrostomy tube. R3's bed linens were soiled with dried rings of urine of different colors (brown, yellow, pinkish brown) on the bedding beneath her. V21 scrubbed the dried stool from R3's back as R3 called out Ouch. V22 stated they were just getting to her this morning and were not sure when the night CNA had last provided care. V23 Licensed Practical Nurse came in the room to assess R3's nephrostomy and said this morning almost every person was complaining about the night CNA, and they had do not returned the CNA so she…
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 before2024-07-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a prescribed scalp treatment was provided to a resident with a diagnosis of psoriasis. This applies to 1 of 17 residents (R1) reviewed for quality of care in the sample of 17. The findings include: R1's face sheet shows she is a [AGE] year-old female with diagnoses including morbid obesity, epilepsy, major depressive disorder, seborrheic dermatitis, arthritis multiple sites, and psoriasis vulgaris (plaques or scales to form on skin including scalp). On 7/22/24 at 9:22 AM, R1 was lying in bed, white scaly buildup was on her scalp. She (R1) stated she has not had her hair washed in three weeks. On 7/23/24 at 8:25 AM, R1 was in her room scratching her head, white scaly buildup remained on her scalp. She (R1) stated she is supposed to get showers on Tuesday and Friday but has not had her hair washed because they do not have a shower chair. On 7/23/24 at 1:17 PM, V11 (Certified Nursing Assistant/CNA) stated R1 transfers using a…
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 before2024-07-24 · 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 fall interventions were in place for a resident who is a high risk for falls. This applies to 1 of 17 residents (R4) reviewed for safety in the sample of 17. The findings include: R4'S face sheet shows R4 is [AGE] year-old male with diagnoses including unspecified dementia, abnormalities of gait and mobility, osteoarthritis, history of falling, vascular dementia, cognitive communication deficit. On 7/22/24 at 12:45 PM, R4 was observed in his room lying in bed with his eyes closed, a folded floor mat was in his room against the wall and not on the floor next to his bed. On 7/23/24 at 9:25 AM, V10 (Licensed Practical Nurse/LPN) stated R4 is alert to self, he is a fall risk and lays down after meals. V10 stated R4 should have a low bed and gets up at times without assistance. On 7/23/24 at 1:13 PM, V11 (Certified Nursing Assistant/CNA) stated R4 is alert to self, confused, fall risk, he should have the floor mat on the floor next 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 · D2024-07-24 · 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 fortified potatoes were provided during the noon meal for a resident with significant weight loss. This applies to 1 of 6 residents (R6) reviewed for weight loss in the sample of 17. The findings include: R6's face sheet shows he is an [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, chronic kidney disease and history of falling. On 7/22/24 at 9:33 AM, R6 was sitting in his wheelchair in his room, he appeared thin. He (R6) stated he has lost weight and not sure why. R6 stated he did not know if he was receiving nutritional supplements. On 7/22/24 at 11:50 AM, R6 was in the dining room feeding himself using his right hand. He (R6) was served a ground pork sandwich and fries. He (R6) was not served fortified potatoes. On 7/23/24 at 10:17 AM, V9 (Dietitian) stated R6 triggered for significant weight loss last month, he (R6) should be…
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 · D2024-07-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure insulin was labeled with an opened date for 3 of 17 residents (R44, R65, R225) reviewed for medications in the sample of 17. The findings include: On 07/23/24 at 10:54 AM, in the South Front medication cart, R44's Lantus insulin vial and Lispro insulin pen were opened and not dated. R65's Lantus insulin pen was opened and not dated. R225's Glargine insulin was opened and not dated. V18 Licensed Practical Nurse stated these are garbage now, they should be labeled with an open date, so we know how long they are good for. R44's Physician Orders for July 2024 shows an order Insulin Lispro Subcutaneous Solution Pen-Injector 100 unit/ml inject as per sliding scale and Lantus Subcutaneous Solution Pen-Injector 100 unit/ml Inject 5 unit subcutaneously at bedtime for diabetes. R65's Physician Orders for July 2024 shows an order Insulin Glargine Subcutaneous Solution Pen-Injector 100 unit/ml Inject 5 units subcutaneously one time a day for diabetes. R225's Physician Orders for July 2024 shows an order Insulin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-22 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide sufficient nursing staff to meet the care needs of the residents. This failure has the potential to affect all 78 residents residing in the facility. The findings include: The facility provided census shows there were 78 residents residing at the facility on 2/22/24. On 2/22/24 at 8:40 AM, R5 said the facility does not have enough staff, and she does not routinely get showers or bed baths, she said last week no one ever came to even offer her a shower and it has probably been 2 weeks since she had a bed bath even. On 2/22/24 at 8:55 AM, V6 (CNA) said the facility is short today and when they have only 3 CNAs on the north end it can be hard to keep up with showers and every 2-hour incontinence care and checking residents. On 2/22/24 at 9:25 AM, R4 said she has not been getting showers. R4 said it has been about 3 weeks and she is discouraged because no one is taking her to shower and said, I would give about anything to get a shower. On 2/22/24 at 9:26 AM, R10 said the facility is having staffing issues…
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 before2024-02-22 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
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 dependent on staff for activities of daily living/ADL's received showers as scheduled, and failed to ensure incontinence care and turning and repositioning was completed every 2 hours for 5 of 6 residents (R1, R2, R3, R4, R5) reviewed for ADL care in the sample of 11. The findings include: 1.) On 2/22/24 at 9:50 AM. R2 was lying in bed. V7 (Certified Nursing Assistant/CNA) was providing incontinence care to R2 to get him dressed and out of bed. R2 said no one had turned or changed him since 6 AM. At 9:50 AM, V7 said the facility is short CNAs today so she was pulled from the south side to the north side to help and had not been in to provide morning care to R2 until now. When V7 turned R2 to his side his incontinence brief was soaked with urine that went through the pad and bottom sheet that were underneath him down to his mattress. His shirt had a visible wet ring that went halfway up his back. V7 said it is likely he had not been changed since 6 AM because his shirt is soaking wet. V7 said R2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-30 · 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 residents were free from misappropriation of money. This applies to 1 of 8 residents (R1) reviewed for misappropriation in the sample of 8. The findings include: On October 30, 2023, at 9:53 AM, R1 stated, her son had given her $100.00 in case she needed anything to buy. She had the money locked in a little black lock box in her bedside table. You need a key to open up the lock box. The key was kept in her purse in a different drawer. She stated, on a Saturday she asked one of the CNAs (Certified Nursing Assistants (V10 CNA)) to get her some food. She told V10 CNA to take $40.00. V10 CNA got her food and brought her back $20.00. She asked, V10 CNA to put the $20.00 back in the lock box in the drawer. She stated, V10 CNA put the money back. She should have had $80.00 in the lock box. The next day another girl came in her room and sat on a chair by her bedside table talking with her. The girl put a blanket over the bedside table and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-02 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
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 Activity of Daily Living (ADL) cares including showers were provided for 4 of 4 staff dependent residents (R1, R2, R3, and R4) reviewed for ADLs in the sample of 4. The findings include: 1.) On 10/2/23 at 8:50 AM, R1 said she recently had an issue where her hair became heavily matted, and she had a rat's nest in it due to no one assisting her to brush the back of her hair. She said she has paralysis in one hand, so she needs assistance with bathing and grooming. R1 also said she is not receiving showers at the facility, and no one asks her if she wants a shower, but then they chart she is refusing them. She said the last time she received a shower was approximately 13 weeks ago. On 10/2/23 at 11:20 AM, V2 (R1's family member) said there was a recent situation on 9/23/23 where she came to the facility to attend R1's birthday party and when she got there around 12:20 PM, R1 was not up or dressed. She went and found staff to assist 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 before2023-08-03 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain a system of reconciliation of narcotic medications in their emergency pharmacy supply system. This failure has the potential to affect all residents in the building. The findings include: The facility's roster printed on 8/3/23 showed 71 residents residing in the building. The facility's incident report dated 7/25/23 showed, At approximately 2:00PM on 7/19/23 administrator was notified of a medication punch card that contained 8 Hydrocodone 10-325mg pills that were not secured in the facility Stat Safe (emergency medication supply system) on 7/7/23 .Review of records indicate that nurse (V8-Licensed Practical Nurse) signed receiving 8 Hydrocodone 10-325mg pills for the pharmacy delivery on 7/7/23. Facility was searched for the missing medication and unable to locate the medication punch card containing the 8 Hydrocodone 10-325mg pills . A phone call was placed to V8 during this investigation with no return call received. The facility's pharmacy consolidated delivery sheet dated 7/7/23 showed V8 signed for a Stat…
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 · F2023-06-29 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the recipe for pureed big mac for 2 of 2 residents (R6, R32) reviewed for puree diets in the sample of 17. The findings include: The facility's 6/27/23 menu showed a big mac hamburger for lunch. The facility's recipe for pureed big mac showed each hamburger on a bun had a slice of American cheese and ½ cup Thousand Island dressing. On 06/27/23 at 11:00 AM, V7 cook, placed four hamburgers, shredded lettuce, and beef broth into the food puree machine. V7 stirred the machine contents and added additional beef broth. V7 did not add any buns, cheese or dressing to the puree machine contents. At 11:05 AM, V7 said there are two residents on a puree diet, R6 and R32. At 11:50 AM, R6 and R32 were seated in the dining room with their puree diet in front of them. R32 was feeding himself his pureed lunch. On 06/28/23 at 09:15 AM, V6 Dietitian said it's important to follow recipes to provide the appropriate servings of carbohydrates, calories,…
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 before2023-06-29 · 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 the three-compartment sink and dishwasher had the proper concentration of sanitizing solution prior to use, failed to ensure pureeing equipment was sanitized between uses, and failed to ensure cooler temperatures were at a safe temperature to prevent food borne illness. This has the potential to affect all 68 facility residents. The findings include: The facility's 6/28/23 Resident Census and Condition of Residents form showed 68 residents in the facility. 1. On 6/27/23 at 9:00 AM, V3 Dietary Manager tested the dishwashing machine sanitizer concentration using a quat (quaternary) test strip. After numerous attempts, the test strip never attained the appropriate color. The dishwashing sanitizer used in the dish machine is chlorine based. The chlorine sanitizer container was attached to the dishwashing machine via a tube system. At 9:15 AM, V3 tested the third sink in the three compartments sink to check sanitizer concentrator level using a chlorine test strip. After numerous attempts, the test strip…
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 before2023-06-29 · 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 resident dignity was maintained during personal care for 1 of 1 resident (R6) reviewed for dignity in the sample of 17. The findings include: R6's face sheet printed on 6/28/23 showed diagnosis including but not limited to intracerebral hemorrhage in brain stem, hemiplegia, hemiparesis, dementia, depression, anxiety, obesity, and functional quadriplegia. R6's facility assessment dated [DATE] showed moderate cognitive impairment and total staff dependence needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The same assessment showed R6 is always incontinent of urine and bowel. On 6/27/23 at 9:21 AM, R6 was transferred from the wheelchair to the bed by V11 and V12 (CNAs-Certified Nurse Aides). R6 was incontinent of urine and her brief was removed. Pericare was performed and she was rolled from side to side several times. A new brief and her pants were put on. R6 was naked from the waist down during care 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 · D2023-06-29 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physicians orders were followed for 1 of 1 resident (R46) reviewed for physician's orders in the sample of 17, and 1 resident outside of the sample (R15). The findings include: 1. R46's admission Record, printed by the facility on 6/29/23, showed she had diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, weakness, paroxysmal atrial fibrillation, and congestive heart failure. R46's facility assessment dated [DATE] showed she was cognitively intact and required extensive assist of one staff member for bed mobility, transfers, and toileting. On 6/27/23 R46 was interviewed in her room. R46 was alert and oriented. R46 said she has had several UTIs (urinary tract infections). On 6/29/23, during a review of R46's lab results and R46's urinalysis that indicated the need for a culture and sensitivity was not in R46's electronic medical record. A Physician's FYI/Order request form dated 5/30/23 showed R46's physician was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document a change of condition for 2 of 2 residents (R38, R49) reviewed for hospitalization in the sample of 17. The findings include: 1. R49's admission Record shows she was admitted to the facility on [DATE] and re-admitted [DATE]. The same record documents her most recent hospital stay was 5/20/23 to 5/30/23. R49's Nursing Progress notes for 5/20/23 document Order Summary and Facesheet faxed to the hospital. The Progress Notes do not show when R49 left the facility, why she was sent out to the hospital, or any assessment regarding her reason for transfer. The Progress Notes do not indicate any physician notification or family notification of the transfer. The assessments were reviewed and no documentation regarding a transfer was documented. The 5/30/23 transfer quick review form from the hospital documents R49 was admitted on [DATE] with respiratory distress, after she was sent from dialysis for shortness of breath. On 6/29/23 at 8:50 AM, V2 DON…
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 before2023-06-29 · 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 incontinence care was provided in a manner to prevent cross contamination for 2 of 2 residents (R31, R6) reviewed for infection control in the sample of 17. The findings include: 1. R31's Facesheet printed on 6/28/23 showed diagnosis including but not limited to encephalopathy, parkinson's disease, dementia, and spondylosis (degeneration of vertebral column). R31's Facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance needed for bed mobility, transfers, dressing, toilet use, and personal hygiene. The same assessment showed R31 is always incontinent of urine and bowel. The facility provided Pressure Ulcer Log showed R31 has a stage 2 ulcer to the sacrum. Treatment for the pressure ulcer included to apply barrier cream during incontinent episodes. R31's MAR (Medication Administration Record) for June 2023 showed the recent completion (6/21/23) of an antibiotic (nitrofurantoin) to treat ESBL…
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 · D2023-06-29 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to offer and provide education regarding the Pneumonia vaccination for 3 of 5 residents (R8, R14, R26) reviewed for immunizations in the sample of 17. The findings include: On 06/28/23 at 12:48 PM, V5 Infection Preventionist said if residents are not up to date on their Pneumonia vaccinations complications could include getting Pneumonia. Pneumonia affects the lungs and could cause respiratory issues and death. 1. On 06/28/23 at 12:48 PM, V5 Infection Preventionist said the CDC (Centers for Disease Control and Prevention) guidelines should be followed for all facility residents. R8's Facesheet indicates R8 is an [AGE] year-old female with diagnosis of aphasia, obstructive sleep apnea, dementia, moderate protein calorie malnutrition and a Stage 4 pressure ulcer. R8's Immunization Report showed she received the PCV (Pneumococcal conjugate vaccine) 13 immunization on 11/6/2018. There was no documentation any Pneumonia vaccines were offered to R8 or her…
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 before2022-05-05 · 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 the observation, interview and record review the facility failed to ensure dishes were properly sanitized prior to use. This has the potential to affect all residents in the facility. The findings include: The CMS 672 form dated 5/3/22 shows 81 residents reside in the facility. On 5/3/22 at 11:10 AM, dietary staff were loading filled water and juice pitchers onto a resident service cart to be used for the lunch meal. At 11:15 AM, V12 (Dietary Aide) was asked to run a sanitization test on the dishwasher. V12 turned on the dishwasher and ran a test rack through it. At the end of the cycle, V12 lifted the dishwasher door and placed a test strip into the water dripping off the door edge. The test strip was compared to the color key on the test vial and showed a ppm level (parts per million) of 10 ppm. V12 stated the color is off and it should be testing higher than 10 ppm. V12 ran a second test load and dipped the test strip into the water dripped off the door edge. Again, the test strip read a level of 10 ppm. V12 returned to loading drinks onto the cart and did not notify any…
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 before2022-05-05 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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 in an appealing and appetizing manner for four of four residents (R2, R38, R47, R62) reviewed for meal service in the sample and six residents (R3, R8, R17, R21, R57, R277) outside the sample. The findings include: On 5/3/22 at 1:39 PM, R47 stated she eats in her room and when her food arrives it is cold. She stated the meal does not include everything on the menu, such as today, there was no dessert. R47 stated they bring a ticket and ask what you want, but then do not bring what you order. This morning she ordered eggs with cheese, and she received eggs, but there was no cheese. She stated she did not get the bacon and fruit she ordered either. R47 stated the time of meals varies every day as well and some days it arrives on time and some days it is almost 10 AM before breakfast arrives. R47 stated there have been times of ordering a salad or soup and never getting it. She has ordered a hamburger and it arrive without a bun. She stated if you ask for something, they always say there is…
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 before2022-05-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide showers for dependent residents for 2 of 2 residents (R6, R23) reviewed for Activities of Daily Living in the sample of 21. The findings include: 1. R23's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Epilepsy, Encephalopathy, Muscle Weakness, Insomnia, Seborrheic Dermatitis, and Major Depressive Disorder. R23's facility assessment dated [DATE] showed she has no cognitive impairment and is dependent upon staff for all cares. On 5/3/2022 at 10:03 AM, R23 was laying in her bed in her room. R23 had red and white patchy areas visible on her face, neck, and arms. R23's hair was visibly greasy. On 5/3/2022 at 10:03 AM, R23 stated she is not receiving showers. R23 stated she was told she was supposed to get two showers a week. R23 stated she is going on about two weeks without a shower at this time. R23 stated, I'm getting really frustrated because I was told someone was putting down that I 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 · Dcited before2022-05-05 · 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 document a resident fall for 1 of 3 residents (R267) reviewed for falls in the sample of 21. The findings include: R267's admission record documents he was admitted to the facility on [DATE] with multiple diagnoses including Dementia, Weakness and a Fracture of the Right Femur. On 5/3/22 at 10:45 AM, V11 (R267's wife) reported R267 had fallen at home and required hip repair surgery, and he was admitted to the facility for therapy. She stated he has dementia and had fallen at home a couple of times before breaking his hip. She stated he had a fall in the facility already, and he had only been there since Friday. V11 stated he was on the 300 wing, and they are short of staff, and it seems no one was watching him, and he tried to get himself to the bathroom. V11 stated after learning of the fall, she requested a room change to get him closer for staff to monitor. In his new room he had a low bed and mats by the bed. V11 stated she learned 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 · Dcited before2022-05-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have a diagnosis and order for an Indwelling Catheter and failed to ensure a daily dressing change was completed as ordered for a Suprapubic Catheter for 2 of 2 residents (R29, R6) reviewed for catheters in the sample of 21. The findings include: 1. R29's admission record shows he was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including Acute Respiratory Failure and Diabetes. The 5/4/22 Physician order summary report documents an order for catheter care every shift. The orders do not include a required diagnoses, size of the catheter, or any orders to change or flush the catheter. On 5/04/22 9:54 AM, R29 stated he has had the catheter for two weeks now. He stated he had a lot of abdominal pain and could not urinate, so the nurse drained his bladder, but then it filled up again and he could not go on his own. R29 stated the nurse then put the catheter back in and left it to drain with the bag. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$407,176 in federal fines across 7 penalties. 1 Medicare payment denial on record.
- $41,243 — penalty dated 2025-08-26
- $102,105 — penalty dated 2025-02-07
- $14,050 — penalty dated 2024-12-27
- $22,970 — penalty dated 2024-09-24
- $125,694 — penalty dated 2024-07-24
- $14,050 — penalty dated 2024-05-28
- $87,064 — penalty dated 2023-09-20
- Medicare payment denial — starting 2023-10-19 for 12 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 | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 2 of 5 | 1.7 | +0.3 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 |
|---|---|---|---|
| CONSTACE MARIE MENDOLIA 2009 IRRV TR | Organization | DIRECT OWNERSHIP INTEREST | since 12/31/2009 |
| JOSEPH C TUTERA 2009 IRREVOCABLE TRUST | Organization | DIRECT OWNERSHIP INTEREST | since 12/31/2009 |
| MARY MARGARET CUNNINGHAM 2009 IRRV TR | Organization | DIRECT OWNERSHIP INTEREST | since 12/31/2009 |
| TUTERA, JOSEPH | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/14/1994 |
| WALNUT CREEK MANAGEMENT COMPANY LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/08/2025 |
| BLOOM, RANDALL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/1997 |
| BROOKS, KILEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/15/2018 |
| RITTER, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| ZAMAN, ASAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| DEKALB HEALTH ENTERPRISES INC | Organization | ADP OF THE SNF | since 12/31/2009 |
| GROVES, REGENA | Individual | ADP OF THE SNF | since 05/01/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 11 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.
5 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 $1.7M 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 145958. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-24, 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.