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Elevate Care Des Plaines

1660 Oakton Place, Des Plaines, IL 60018 · For profit - Limited Liability company · 200 certified beds · (847) 299-5588 Medicare & Medicaid certified

Call the home — (847) 299-5588 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 202510 actual-harm citations$248,079 in federal fines4 Medicare payment denials
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
  • it has 10 actual-harm citations
  • a high number of inspection citations overall (37) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $248,079 in federal fines (most recent 2025-01-16)
  • about 22% 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1400 E Touhy Ave Ste 240 · (847) 510-3034 · Call to confirm hours
Pharmacy
1500 Lee St · (847) 296-7786 · Call to confirm hours
Grocery
1045 E Oakton St · (847) 795-1100 · Call to confirm hours
Park
Lake Park0.4 mi
1069 Howard Ave · Typically dawn to dusk

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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.9%13.4%15.4%better
Long-stay residents who lose too much weight4.6%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms27.3%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%3.1%3.3%better
Long-stay residents whose ability to walk worsened7.5%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication16.4%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers10.7%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control11.6%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.9%21.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.5%63.1%79.4%better
Short-stay residents rehospitalized after admission27.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit11.0%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days3.142.021.67worse
Long-stay outpatient ER visits per 1,000 resident days3.112.221.80worse

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.

54.7% 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 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.7%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
37.0%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 37.0% 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 46 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 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 41% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.7%CMS range 41.4–67.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.7–15.810.7%Oct 2022–Sep 2024no 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 discharge37.0%56.6%Oct 2024–Sep 2025CMS 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 discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge32.6%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.6%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.8%CMS range 5.5–14.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 2022–Sep 2024CMS 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

1.38
RN hours/ resident / day
0.41
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.80
Total nurse hours/ resident / day
1.06
RN hoursweekends
44.6%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 200 beds and averages 107.2 residents a day — about 54% occupied, or roughly 93 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.80 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.38 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.38 hrs/resident/day on weekends vs 3.97 on weekdays — 15% thinner on weekends. RN hours go from 1.51 to 1.06 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

1
deficiencies at the latest standard inspection (2024-08-22)
5
at the previous standard inspection (2023-08-25)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

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.

ABCDEFGHIJKL

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.

37 citations, most serious first. The 20 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2025-07-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident remained free from staff to resident abuse for one of three residents (R1) reviewed for abuse. This failure resulted in R1 sustaining physical injuries and R1 being transported to the emergency department for treatment, ultimately resulting in R1's request discharge against medical advice due to fear and dissatisfaction with the facility. R1 is a [AGE] year-old with diagnoses including heart failure, epilepsy, hypertension, hyperlipidemia and anxiety disorder. On 7/18/25 at 1:50 PM, V1 (Administrator) said she was the abuse prohibition coordinator and was present in the building due to flooding in the basement that evening she was trying to address when V4 nurse had an altercation with the resident R1. V1 indicated she was told by the resident that V4 hurt his wrists and chest during the altercation and that the resident called 911 and police and fire department came to speak with resident. V1 said she personally walked…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-02-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure for hydration and tube feeding tube care by not ensuring that a resident received the recommended amount of fluids for a resident who is dependent on tube feeding for nutrition. This failure applied to one (R1) of four residents reviewed for hydration and resulted in R1 being hospitalized with diagnoses including dehydration, high blood sodium, and hypotension (low blood pressure). Findings include: R1 is a [AGE] year-old male with a diagnoses history present on admission of Brain Damage due to Oxygen Deprivation, Bacterial Infection, Epilepsy, Congestive Heart Failure, Stage 4 Pressure Ulcers, Acute Kidney Failure, UTI's, Trach Use, and Feeding Tube Use who was admitted to the facility 07/27/2024. On 02/10/2025 at 10:29 AM Observed R1 in his room lying in his bed unable to speak, bed bound, and receiving a enteral nutrition via a tube feeding. R1's current care plan documents he has potential 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly transfer one resident (R1) and ensure that R1 was wearing proper footwear during the transfer. This failure resulted in R1 being hospitalized and sustaining a fracture to the neck. Findings include: R1 is an [AGE] year old female who admitted back to the facility on [DATE] and was discharged to the hospital on 1/10/2025. R1 has multiple diagnoses including but not limited to the following: type II DM, dementia, psychosis, HTN, dysphagia, difficulty in walking, unsteadiness on feet, disorientation, and need for assistance with personal care. V3's (Licensed Practical Nurse) progress note dated 1/5/2025 at 10:00AM states in part but not limited to the following: V4 (Certified Nursing Assistant) was transferring R1 from wheelchair to the shower chair. V4 said R1 began to slide and was lowered to the floor. R1 was wearing slippers at the time of transfer. On 1/15/2025 at 11:15AM, V4 said I was going to give R1 a shower. R1 was previously a resident…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-10-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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 obtain a urine specimen from a catheter in a timely manner, document indwelling catheter output, ensure catheter care was provided and identify/respond to signs and symptoms of a UTI (Urinary Tract Infection) in a timely manner for 2 of 3 residents (R1, R3) reviewed for indwelling catheters in the sample of 3. These failures resulted in R1 requiring emergency treatment and hospitalization for a severe UTI with sepsis. The findings include: 1. The facility's Grievance Form dated 8/30/24 showed a representative from the Public Guardian's Office expressed concern regarding a phone call received by the emergency department. The ER (emergency room) informed them that R1 was admitted to the hospital with a sludged catheter. The back page of this form titled, Facility Grievance - Written Decision Form was blank. There were four sections including: Facility information, Grievance/complaint information; Investigation and Results; Was the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-06-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the wheelchair locking mechanism was engaged and failed to supervise one high risk for falls resident (R1) in a sample of 3 residents. This failure resulted in R1 falling out of an unlocked wheelchair while sitting in an unsupervised dining room. R1 sustained bruising to the left side of face and a cut above her left eye which, required hospital evaluation and 4 sutures above left eye. Findings include: Facility's reportable to state agency regarding R2 documents in part: Date of Occurrence: 05/31/24, R1 was noted on dining room floor in front of her wheelchair. R1 was laying on her left side and noted with a small cut to above her left eye. Nurse on duty provided first aid. R1 was sent to local hospital for further evaluation. R1 returned from local hospital with four sutures above left eye. Interviews: V10 (Activity Aid) states R1 participated in a group activity. After the activity V10 transported R1 out of the activity room and was instructed by nurse to bring R1 in the dining room. V10 placed R1 by the table in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to supervise a high risk for falls resident (R2) in a sample of 5 residents. This failure resulted in R2 sitting in a wheelchair at the nurse's station, falling asleep and leaning forward and falling out of his wheelchair to the ground face down. R2 sustained small laceration to bridge of nose, required hospital evaluation and required two sutures to the nose. Findings include: Facility's reportable to state agency regarding R2 documents in part: Date of Occurrence (11/20/23), R2 was sitting in a wheelchair at nurse's station and fell asleep, leaned forward, and fell from the wheelchair. R2 was evaluated by the nurse on duty to have active ROM x 4 with c/o (complaint of) pain to head and noted small laceration to the bridge of R2's nose. NOD (Nurse on Duty) provided first aid. R2 was transferred to hospital as a witnessed fall. While at the hospital, received two sutures to the bridge of nose and returned. Interviews: V8 (Certified Nursing Assistant/CNA) states R2 had been up at nurse's station. V8 was in hallway throwing 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-01-02 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, this facility failed to provide the necessary services, identify a decline, implement interventions, and evaluate the effectiveness of interventions to prevent the decline in range of motion. This affected one of three residents (R1) reviewed for a decline in functional abilities. This failure resulted in R1 developing a contracture of right hand and is unable to extend fingers. Findings include: R1's medical record notes R1 with diagnoses including, but not limited to, tracheostomy, ventilator dependent, left knee contracture, gastrostomy, nontraumatic intracerebral bleed, stroke with hemiplegia affecting right side, cardiac arrest, generalized muscle weakness. On 12/26/23 at 9:18 AM, R1's family member stated that R1's hands are contracted because he is not receiving therapy. R1's family member stated that R1 is supposed to wear a splint on right hand, but she never sees R1 wearing it and now R1's right hand is contracted. On 12/26/23 at 1:30 PM, R1 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-12-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow its Accident/Incidents Reporting policy by not completing an incident report, failing to document in the progress notes, failing to assess and monitor for any changes of condition, and failing to notify the physician and family immediately after an incident. The facility also failed to follow its Fall Prevention and Management policy by not implementing fall interventions and failing to update fall care plan after a fall for two (R1, R2) of three residents reviewed for falls. These failures caused a delay in treatment and hospitalization of R1 who sustained a left femoral neck fracture that required surgery. Findings include: 1.) On 12/5/23 at 9:52AM, observed R1 lying in bed. She is awake but confused and restless. Her blanket is by the foot part of her bed. The bed is not on the lowest position. The floor mattresses are folded on the floor. The call light is not within reach. The abductor wedge is at the bedside. Called V9…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow the fall prevention policy to develop, implement, reevaluate the effectiveness of interventions to prevent or reduce the risk of falling for a resident with dementia, poor safety awareness, and high risk for falls. This failure affected one of three residents (R1) reviewed for fall prevention intervention. These failures resulted in R1 being involved in a fall incident causing pain to the left hip area. R1 was sent to the local hospital and evaluated and treated for a displaced left femur fracture. Findings include: R1's face sheet shows diagnosis of Parkinson's disease, Alzheimer's with late onset, tremors, abnormalities of gait and mobility, dementia. MDS dated 7.21.23 section C denotes BIMS score of 7(cognitively impaired). Section G for bed mobility denotes R1 is extensive assist with one-person physical assist, transfer denotes R1 is extensive assist with one-person physical assist. Balance during transition and walking 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-09-12 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pain management after a fall for a dementia resident observed by the resident's family to have facial grimacing and acting out of character and complaining to staff of left hip pain during dressing. This affected one of three residents (R1) reviewed for pain management. This failure resulted in the staff being notified that R1 was in pain by a family member post fall and R1 not receiving any pain medication. R1 was transferred to the local hospital where R1 was diagnosed and treated with a displaced left femur fracture. Findings include: On 9.6.23 at 11:26am V2 (CNA) said she was assigned to work with R1 on 8/12/23 7-3:00pm shift. V2 said she assisted R1 with breakfast that morning, R1 was in the bed. V2 said she was in the room caring for another resident when the housekeeper informed her that R1 fell. V2 said when she arrived to R1's room and R1's roommate was trying to assist R1 up from the floor. V2 said she intervened, V2 said R1 was laying…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-17 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide 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, observation, and record reviews, the facility failed to provide timely assistance with toileting/incontinent care and personal hygiene for three (R4, R5, R6) of four residents reviewed for ADL care.Findings include:1. R4 is a [AGE] year-old, female, initially admitted in the facility on 10/20/22 with the following diagnoses: Type 2 Diabetes Mellitus without Complications; Encounter for Attention to Tracheostomy; Dependence on Respirator Status; Morbid Obesity with Alveolar Hypoventilation; Chronic Obstructive Pulmonary Disease, Unspecified; Neuromuscular Dysfunction of Bladder, Unspecified; and Lymphedema, Not Elsewhere Classified. MDS (Minimum Data Set) dated 04/25/26 recorded R4's BIMS (brief interview for mental status) score is 15 which means little to no impairment in cognition.On 06/15/26 at 10:50 AM, V9 (Certified Nurse Aide, CNA) was observed providing incontinent care on R4. R4 has indwelling urinary catheter draining to urinary bag. R4 does not wear incontinent brief. R4 uses…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2026-03-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its Respiratory Care Equipment and Supplies policy by failing to change ventilator circuits and filters. This applies to 1 of 3 residents (R1) reviewed for ventilator (Vent)/Tracheostomy (trach) care in a sample of 3.The findings include:R1 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE].A review of the face sheet documented that R1 was admitted with an admitting diagnosis, including tracheostomy, ventilator dependence, and neuromuscular dysfunction of the bladder.On 3/24/26 at 10:50 AM, R1 was observed in his bed with his spouse, with a Vent/Trach setup and cough assistance. R1 was observed with a dirty-looking ventilator circuit (blue tube from ventilator to tracheostomy) and a filter dated 2/20.On 3/24/26 at 10:50 AM, R1 and his spouse (V4) stated, The facility is not changing the vent circuit every month, which can cause infection. I have a different type 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-02-25 · tag F0906 — widespread
    Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility experienced a power failure related to an area wide power outage. The facility's backup generator failed to provide back up power for the facility as it is designed to do during a power outage. The facility failed to ensure the safety of all residents dependent on life-sustaining equipment related to inability to provide electricity to life sustaining devices during the power failure. The facility failed to document the generator was in working order by completed weekly testing and monthly testing under load to ensure the backup generators availability in an emergency. Findings include:V1, Administrator on 02/09/26 3:18PM- stated On September 20, 2025, at 9:26 PM, the primary utility power failed. The facility's emergency generator did not engage. V1 said, I came to facility around 9:45PM or before 10PM and the door was already propped open due to V12 (Maintenance Director) opening it. The facility was all dark and I pulled out my emergency prep binder and contacted all the consultants to come in and we pulled out the binder with…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents dependent on life-sustaining medical equipment received the specialized respiratory care and continuous clinical monitoring essential to prevent life-threatening complications. during a total facility power loss. These failures affect all residents (R1-R15) who are ventilator dependent. Findings include:R1's care plan states that she is a [AGE] year-old female with diagnoses including, in part, Chronic Respiratory Failure and COPD.V1, Administrator stated on [DATE] at 9:26PM: The emergency backup generator failed to activate, resulting in a total loss of electrical power to the specialized ventilator unit. The facility remained without electrical power for 3 hours and 15 minutes, until power was restored on [DATE] at 12:41AM.V11 on [DATE] at 1:31PM stated that she documented in the EHR (Electronic Health Record) the final clinical assessment of R1's respiratory status, including ventilator settings and suctioning needs for R1. R1'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders by failing to monitor and apply a resident's negative pressure wound therapy and dressing for a resident with necrotizing fasciitis to the right foot. These failures affect one of three residents reviewed for wound care. This failure resulted in R2 not receiving wound treatment for 5 hours, calling 911, and being transported to local emergency room. Findings include: R2 was admitted to the facility on [DATE] with a diagnosis of necrotizing fasciitis, sepsis, type II diabetes, polyneuropathy and anxiety disorder. R2's brief interview for mental status dated 4/14/25 documents a score of 15/15 which indicates cognitively intact. R2's physician order dated 4/9/25 documents: Right dorsum and plantar foot - Cleanse with Normal Saline Solution (NSS)/wound cleanser, apply negative pressure wound therapy (NPWT) at 125 mmHg (milimeters of mercury) continuous setting every day shift every Tuesday, Thursday, Sunday and as needed. On 4/22/25…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-13 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure for housekeeping by not ensuring the rooms and medical equipment of residents who are totally dependent on staff for care and assistance with activities of daily living, were consistently and adequately cleaned and sanitized. This failure applies to four of four residents (R1, R2, R3, R4) reviewed for environment. Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history present on admission of Brain Damage due to Oxygen Deprivation, Bacterial Infection, Epilepsy, Congestive Heart Failure, Stage 4 Pressure Ulcers, Acute Kidney Failure, UTI's, Trach Use, and Feeding Tube Use who was admitted to the facility 07/27/2024. On 02/10/2025 at 10:29 AM Observed multiple dresser drawers near R1's bed open and a mild odor present. On 02/10/2025 at 10:54 AM Observed R1's oxygen machine with visible dust and particles. V5 (Registered Nurse) was present and verbally confirmed the observation and stated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-13 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for feeding tube care by not following physician orders of daily cleansing and dressing of feeding tube site for residents dependent on enteral nutrition. This failure applied to four of four (R1, R2, R3, and R4) residents reviewed for quality of care. Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history present on admission of Brain Damage due to Oxygen Deprivation, Bacterial Infection, Epilepsy, Congestive Heart Failure, Stage 4 Pressure Ulcers, Acute Kidney Failure, UTI's, Trach Use, and Feeding Tube Use who was admitted to the facility 07/27/2024. On 02/10/2025 at 10:29 AM Observed R1 in his room lying in his bed unable to speak and bed bound. Observed V3 (Registered Nurse) uncover R1's feeding tube surgical site to reveal the site to be without a bandage/dressing and with a noticeable scab present. V3 stated feeding tube site dressings should be changed every night shift and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and records reviews the facility failed to provide a recliner wheelchair to a dependent resident. This failure affected one (R12) resident out of three residents reviewed for resident rights who expressed a desire to get out of bed and interact with the environment. Findings Includes: R12 is [AGE] years old admitted to the facility 09/08/23 with diagnoses including but not limited to multiple sclerosis, Sacral ulcer, Chronic anemia, and protein energy undernutrition. MDS (minimum data set) dated 06/17/2024 reads R12 uses a wheelchair for mobility. On 08/20/24 at 10:30AM during facility rounds R12 observed to be in bed and said, I want to get out of bed, but I don't have a wheelchair. I don't remember when the last time was, I got up. I asked the nursing assistants, but I was told I do not have a chair to get up in. On 08/21/2024 at 10:45 AM Observed V21(Certified Nursing Assistant) getting R12 out of bed to receive a shower. V21 said, I am R12's regular certified nursing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-03 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow Physician Order for transmission-based precautions for 1 resident (R8) and failed to perform hand hygiene to prevent the spread of infectious microorganisms. Findings include: R8 was admitted on [DATE] with diagnosis that includes diabetes mellitus, systemic lupus erythematosus, Anemia, Acute kidney failure, Urinary tract infection, Pneumonia, unspecified organism, Acute respiratory failure, Unspecified Escherichia coli (E. coli), Listeriosis, unspecified-listeria bacteremia, Neutropenia, unspecified-Neutropenic fever, Bacteremia-listeria bacteremia. R8's Physician Order Sheet start date 5/29/2024 documented, in part Contact Isolation Precautions for Klebsiella, in the urine and MRSA of the nares. R8's Physician Order Sheet start date 5/30/2024 documented, in part Strict contact and droplet isolation precautions related to neutropenic status. All care and services provide by staff in room. R8's care plan dated 5/30/2024 documented…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's safety when providing care to prevent a fall for 1 of 3 residents (R3) reviewed for safety in the sample of 9. The findings include: R3's Face Sheet shows that she was admitted to the facility on [DATE] with the diagnoses of tracheostomy, gastrostomy, sepsis, chronic respiratory failure, pressure ulcer, lupus, obstructive uropathy and malnutrition. R3's Minimum Data Set assessment dated [DATE] shows she is in a persistent vegetative state and is dependent on staff for all activities of daily living (ADL) and mobility. R3's ADL Care Plan initiated on 6/28/23 shows that she is totally dependent with two staff assist for bed mobility and bathing. R3's Nursing Notes dated 12/19/23 at 12:00 PM shows, Writer heard called [sic] from CNA (Certified Nursing Assistant) coming from resident room. Writer immediately run [sic] to resident room. Writer noted resident was being changed by CNA, CNA holding resident, resident [sic] body. Writer and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2024-01-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter bag was kept from resting on the floor and failed to secure the catheter tubing for 1 of 3 residents (R2) reviewed for catheters in the sample of 9. The findings include: On 1/19/24 at 9:55 AM, R2 was lying in bed in her room watching TV. R2's urinary catheter drainage bag was near the end of the bed resting directly on the floor. On 1/19/24 at 10:03 AM, V4 (Certified Nursing Assistant/CNA), said a catheter bag should never be on the floor. V4 said the catheter bag should be placed inside a special bag and hung on the bedframe, it should never be on the floor, the floor is dirty, and the catheter bag needs to be clean. On 1/19/24 at 10:07 AM, V5 (CNA) said the catheter bag should not be on the floor because it could get the catheter infected. On 1/19/24 at 10:11 AM, V5 and V3 (Licensed Practical Nurse), were in with R2 to reposition R2. R2's catheter tubing was not secured/anchored to R2's person. On 1/19/24 at 1:03 PM, V9 (Registered Nurse), said they use a leg strap or 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement effective preventive measures according to a resident's plan of care. The facility failed to ensure a pressure relief mattress was operated correctly. This affected one of three residents (R2) reviewed for pressure sore prevention interventions. Findings include: R2's medical record notes R2 with diagnoses including, but not limited to, diabetes, stroke with hemiplegia affecting right dominant side, and generalized muscle weakness. R2's MDS (Minimum Data Set), dated 11/20/23, notes R2's cognition is severely impaired. R2 is totally dependent on staff assistance with hygiene, bathing, dressing, and toileting. On 12/26/23 at 10:35 AM, V4 (Wound Care Coordinator) was observed performing wound care treatment for R2. R2 was observed lying supine in bed. Specialty mattress was observed to be set for 120 pounds. R2 was observed to have a top sheet folded in half under her in addition to the flat sheet. On 12/27/23 at 3:15pm, V4 stated that the low air loss mattress setting is based on the weight 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident from verbal and physical abuse when a CNA (Certified Nurse Assistant) was witnessed forcibly grabbing the resident's legs, threw resident's legs in bed which led to resident forcibly landing in bed and the CNA used inappropriate language directed towards resident. This affected one of three residents (R1) reviewed for abuse. This failure resulted in R1 complaining of mild shoulder pain. Findings include: On 10-3-23 at 10:52 AM, V1 (Administrator) said R1 is alert, oriented x 1-2, and able to make her simple needs known. R1 has behaviors of crying and verbal aggression. V1 said she is not aware of any physical aggression towards others. V1 has seen R1 be verbally abusive towards all staff including V1. V1 said R1 will use profanity at staff and scream at them. V1 said she has not seen any staff verbally or physically aggressive towards R1. V1 said CNA supervisor called V1 about allegation of employee to resident verbal abuse. V1…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement preventative measures appropriately by not following the recommended pressure settings for an alternating pressure air mattress. This deficient practice affects 4 residents (R34, R48, R54 and R62) of 4 residents reviewed for skin alterations in a total sample of 24 residents. Findings Include: 1. On 8/22/23 at 10:30 AM, R34 was in bed on a low air loss (LAL) mattress set on 400 lbs. On 8/22/23 at 10:35 AM showed V10 (Assistant Director of Nursing) the setting of the low air loss mattress of R34 and V10 said that the setting should be close to the resident's weight. I will check the weight and readjust the setting. V10 reported to the surveyor that the weight of R34 is 170 lbs. (pounds). R34's care plan documents: At risk for developing pressure ulcers related to limited mobility and incontinence and multiple wounds. Approach: Use pressure reduction mattress (LAL) when resident is in bed (start date of 1/25/23). R34's weight 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-25 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to do an accurate count of controlled medications by failing to complete the controlled drug receipt/record/disposition form upon receipt of the medications for two of four medication carts affecting five residents (R29, R59, R82, R168, R172) reviewed for controlled medication reconciliation in a sample of 24. Findings include: On 08/23/2023 at 11:19AM during review of controlled medications with V23 (Licensed Practical Nurse/LPN), 3rd floor medication cart was observed with R82's controlled drug receipt/record/disposition form for Lorazepam 2mg tablets with signature of nurse receiving medication, quantity received, and the date was blank. On 08/23/2023 at 11:35AM during review of controlled medications with V24 (LPN), 1st floor medication cart was observed with the following: 1. R29's controlled drug receipt/record/disposition form for Lorazepam 0.5mg tablets with signature of nurse receiving medication, quantity received, and the date was blank. 2. R168's controlled drug receipt/record/disposition form 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to treat the residents with respect and dignity for one of four residents (R42) reviewed for resident's rights in a sample of 24. Findings include: 1. On 08/23/2023 at 11:05AM during medication administration observation, V19 (Licensed Practical Nurse) was observed giving insulin to R42 in the dining room. R42 was sitting in the dining room with two other residents in a four-seater table. All 13 tables in the dining room were observed with at least one resident seated. On 08/23/2023 at 11:12AM, V19 said that she did not provide privacy to the resident and should have. On 08/25/2023 at 10:50AM, V2 (Director of Nursing) said that insulin should be administered in the room. Facility Documents: Policy Title: Resident Privacy and Dignity Rev (Revised/Reviewed) 10/21 Objective: This policy is intended to set out the values, principles and policies underpinning the facility approach to privacy and dignity. Procedure: 1. All residents should: d) be consulted on any matter or activity, which may impinge upon their life…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review the facility failed to keep an indwelling catheter collection bag off the floor for one resident (R6) of three residents reviewed for indwelling catheters in the sample of 24. This failure could result in infection. Findings include: On 8/22/23 at 1:15 PM R6's urinary catheter collection bag was observed on the floor beside her bed. It was not attached to the bedframe. The dignity bag was attached to the bedframe. V30 (Certified Nursing Assistant) said it should be in the bag. It is contaminated. On 8/23/23 at 1:55 PM V2 (Director of Nursing) said that is a dignity and infection control issue. Catheter bags should not be on the floor. Policy: Urinary Catheter Insertion & Maintenance Rev.07/26 (sic) 2. Attach drainage bag to bed frame, below level of resident's bladder-not touching the floor.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-07-22 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure 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 safe refrigerator temperatures and failed to monitor and record the temperatures daily. This deficiency affects all 4 medication refrigerators in the medication rooms reviewed for Medication safety storage. Finding includes: On 7/19/22 at 10:35am, checked the 1st floor medication room with V7 (Agency Registered Nurse). She said that the night shift is the one checking and documenting the log for refrigeration temperatures. She said she cannot find the log. She read refrigerator thermometer at 32 degrees Fahrenheit (F). She said she does not know the normal medication refrigerator temperatures for medication storage. Observed the following medications inside the refrigerator: insulin vials, eye drops, Tubersol vials; Lorazepam bottles; Hydrocortisone acetate Suppositories and Dulcolax suppositories. On 7/19/22 at 10:41am, V2 (Director of Nurses/DON) said that V8 (Maintenance) checks all the refrigerators in the building including the refrigerator in the medication rooms. She said that V8 documents 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-22 · tag F0657 — failed to keep the care plan current — pattern
    Develop 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update a care plan for four of six resident's R20, R25, R31 and R41 reviewed for falls in a sample of 31 residents. Findings include: 1. On 7/22/2022 at 10:30am a record review of R25 care plan indicates a diagnosis of History of falling and Unsteadiness on feet. Occurrence report for indicated that R25 had a fall on 10/16/2021, 12/8/2021, 12/17/2021, 2/7/2022, 3/10/2022, and 6/27/2022. A review of the care plan that did not indicate a revision after the fall on 12/8/2021. 2. On 7/22/2022 at 10:40am a record review of the occurrence report indicated that R31 had a fall on 3/3/2022, 3/12/2022, 4/1/2022, 4/11/2022, 5/9/2022 x2, 5/14/2022, 5/15/2022, 6/13/2022, 6/17/2022, and 6/19/2022. A review of the care plan did not indicate the care plan was revised after the fall on 3/3/2022 and 6/19/2022. On 7/22/2022 at 11:30am V11 (Minimum Data Set (MDS) Coordinator) reviewed with the surveyor, the falls occurrence report, the care plan, and the care plan policy…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-07-22 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to follow the controlled substance policy by failing to account for the usage, disposition and reconciliation of controlled medication. This deficiency affects all 7 residents (R8, R14, R36, R39, R65, R70 and R119) in the sample of 31 reviewed for Medication storage for controlled drugs. The facility also failed to follow medication administration policy by failing to notify physician and document reason of not giving the medication in a timely manner. This deficiency affects one (R45) of 14 residents reviewed for medication administration in the sample of 31. Findings include: On 7/19/22 at 10:55am, Narcotic/controlled drug count and inventory of medication done with V10 (Licensed Practical Nurse/LPN) on 4th floor. Observed controlled/narcotic drug record/disposition form not accounted for the number of medications involving 7 residents. V10 said that she gave the medications earlier at 9am but forgot to document it. V10 said that she should document the narcotic medications given in eMAR (electronic Medication…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-07-22 · tag F0880 — failed to prevent and control infections — pattern
    Provide 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 implement appropriate infection prevention and control practices during medication administration including disinfecting of medical equipment (wrist digital blood pressure manometer and medication plastic tray) after each resident use and failed to change gloves and perform hand hygiene after each procedure. The facility failed to maintain droplet and contact precaution to a newly admitted resident who is not fully vaccinated. The facility also failed to follow transmission-based precaution protocol. This deficiency affects all 7 (R26, R45, R62, R95, R220, R221 and R373) in the sample of 31 reviewed for Infection control and prevention. Findings includes: On 7/19/22 at 11:40am V9 (Registered Nurse/RN) prepared medications for R45 wearing gloves. V9 placed all the medications and Glucometer machine on the small plastic medication tray. She went to R45 using the same gloves. At 11:48am, V9 placed the medication tray on top of the R45'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-22 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to administered medication as per physician orders in accordance with professional standards of clinical practice for one (R52) of seven residents in a sample of 31 residents. Findings include: On 7/19/22 at 11:10 am R52 was observed holding her medicine cup with 6 pills in the cup. On 7/19/22 at 11:15 am V4 and V5 (Registered Nurses) both stated that the nurse is supposed to stay wait the resident to ensure medications are taken before the nurse leaves the resident's room. On 7/19 at 1:05 pm, V6 (Nurse Consultant) stated that nurses are supposed to watch residents take their medication before leaving the room. On 7/19/22 at 2:00 pm an interview was conducted with V2 (Director of Nursing) V2 stated that nurses should stay with residents to ensure the resident takes their medication before the nurse leaves the room. On 7/20/22 at 10:30 am, medication administration history dated 7/1/22 to 7/20/22 includes Duloxetine 20mg 9am, Ferrous sulfate 325mg 9am, Gabapentin 100mg 9am, Metoprolol 25mg 9am, Myrbetriq 50mg 9am,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 perform nail care on one resident (R72) of seven residents reviewed for grooming and hygiene in the sample of 31. Findings include: On 7/20/22 at 11:15 AM R72 was observed to have long fingernails ½ inch past the end of his fingers. R72 said, I've been asking them to cut my nails. They keep saying that they are coming back, but they never cut them. R72's diagnoses include spinal fusion cervical spine and paraplegia. On 7/20/22 at 11:15 AM V20 (Certified Nursing Assistant Scheduler) said, the CNAs (Certified Nursing Assistants) are supposed to cut their nails. I will come back and cut them. I have to go get the equipment. On 7/21/22 at 10:45 AM V2 (Director of Nursing) said, the CNAs and nurses should be checking the length of the nails and trimming as appropriate. A Policy titled Activities of Daily Living indicates, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The job…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement care plan interventions to apply finger flexion glove splint to prevent reduction in Range of Motion (ROM) to resident who is at risk for developing contractures due to functional limitation of hand. This deficiency affects one (R37) of three residents in the sample of 31 reviewed for limited ROM. Findings include: R37 was re-admitted on [DATE] with diagnosis to include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R37's care plan indicates she is at risk for developing/has actual contractures related to hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side. She is on splint: finger flexion glove on left hand, on in AM and off in PM. R37's restorative assessment dated [DATE] indicated Range of Motion (ROM) functional limitation of upper extremity - on one side (left hand). Restorative quarterly evaluation 4/30/22 indicated joint mobility assessment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for 2 of 9 resident's (R31 and R62) reviewed for falls in a sample of 31. Findings include: 1. On 7/19/2022 at 12:30pm V10 (Licensed Practical Nurse/LPN) observed with the surveyor, R31 in the dining room in his wheelchair with his chair alarm not turned on or attached to the resident. At 12:35pm V10 said it should be turned on and attached to the resident because he's a fall risk. On 7/19/22 at 2:10pm V2(Director of Nursing/DON) said all chair alarms should be attached to the resident, turned on and functioning properly. R31's physician's order dated from 6/19/22-7/19/22 indicated that R31 has a diagnosis of Radiculopathy, lumbar region and muscle weakness, low back pain, and unspecified eye-[NAME] Corneal Dystrophy also an order dated 5/16/2022 for a Chair/bed Alarm for fall prevention every shift. A care-plan for falls and to provide wheelchair/bed alarm (clipper…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review the facility failed to stabilize the indwelling urinary catheter for one resident (R72) of five residents reviewed for catheters in the sample of 31. Findings include: On 7/20/22 at 10:40 AM R72 was observed with an indwelling urinary catheter without a stabilization device on the tubing. R72 said that's been missing for days. I asked about it. V19 (Registered Nurse/Wound Care) said, the catheter tubing should be stabilized so it doesn't pull. On 7/21/22 at 10:45 AM V2 (Director of Nursing) said, the CNAs (Certified Nursing Assistants) and nurses should check every shift for the catheter leg band. Facility's Policy on Securing the Indwelling Catheter documents: The American Journal of Nursing indicates, indwelling urinary catheters should be routinely secured to reduce the risk of urinary erosion or accidental dislodgement.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2023-08-25 · tag F0577 — pattern
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 have the State inspection survey results available and accessible to the residents. This deficiency affects all five (R4, R8, R53, R90 and R92) residents reviewed for Resident right to Survey results in a sample of 24. Findings include: On 8/23/23 at 10:30am, during resident council meeting, (R4, R8, R53, R90 and R92) all stated that they are not aware of the State inspection survey results and do not know where to locate the binder. On 8/23/23 at 11:00am, V11 (Activity Director) stated that she sets up meetings for the residents every Friday of the month. V11 stated They should know where to find the binder. Facility document titled: Illinois Long-Term Care Ombudsman Program; Residents Right for people in Long-Term Care Facilities. Your right to participate in your own care: You have the right to see the report of all inspections by the Illinois Department public health from the last five years and the most recent review of your facility with any plan that your facility gave to the surveyors saying how your…

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

    Resident Rights Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$248,079 in federal fines across 4 penalties. 4 Medicare payment denials on record.

  • $71,595 — penalty dated 2025-01-16
  • $45,120 — penalty dated 2024-08-22
  • $89,880 — penalty dated 2024-05-20
  • $41,484 — penalty dated 2023-12-08
  • Medicare payment denial — starting 2025-02-14 for 20 days
  • Medicare payment denial — starting 2024-06-12 for 16 days
  • Medicare payment denial — starting 2023-12-28 for 34 days
  • Medicare payment denial — starting 2023-10-03 for 2 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ELEVATE CARE — 14 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 →

RatingThis homeChain avg
Overall 3 of 52.4+0.6 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 3 of 52.1+0.9 vs chain
Quality measures 3 of 53.6-0.6 vs chain
The other 13 homes this chain runs (chain average 2.4★, 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 / managerTypeRoleShareSince
BARRISH GROUP LIMITED PARTNERSHIPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST16%since 09/01/2014
BARRISH, BURTONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 09/01/2014
BARRISH, JULIANAIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST16%since 01/01/2015
GESUALDO, MARYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 01/01/2021
GESUALDO, RALPHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 09/01/2014
KOZIN, DAVIDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST9%since 09/01/2014
KOZIN, RENEEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST9%since 09/01/2014
JAVIER, JOSEPHIndividualW-2 MANAGING EMPLOYEEsince 10/04/2017
BERGTHOLD, LOUISEIndividualCORPORATE OFFICERsince 09/01/2014
WINTER, THOMASIndividualCORPORATE OFFICERsince 09/01/2014

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$14.2M
Net patient revenuemost recent cost report
-14.4%
Operating marginrevenue minus expenses
$3.5M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 13%Medicare 7%Other / private 80%

This home reported $3.5M paid to related parties — landlords or management companies under common ownership — equal to about 22% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$381per resident / day
operating cost
$11,591per month
≈ monthly operating cost
$333per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 145626. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-22, 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.

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