Evercare At University
1095 University Drive, Edwardsville, IL 62025 · For profit - Corporation · 118 certified beds · (618) 656-1081 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0602, F0607, F0610) — most recent Oct 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (66) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $399,548 in federal fines (most recent 2026-02-11)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.2% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.6% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.1% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.9% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 85.1% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.9% | 14.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 31.3% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 58.3% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 7.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 10.6% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.5% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 4.4% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.7% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.2% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.82 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.10 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
37.3% 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 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 15.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 32 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 37.3%CMS range 27.1–52.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.0–15.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 15.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 25.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 34.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 88.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 3.1–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 118 beds and averages 100.6 residents a day — about 85% occupied, or roughly 17 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.51 hrs/resident/day on weekends vs 3.10 on weekdays — 19% thinner on weekends. RN hours go from 0.31 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
66 citations, most serious first. The 25 most serious are shown; the remaining 41 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-10-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the Facility failed to ensure residents were free from sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 being sexually abused by R3 on 10/5/25 and again on 10/6/25.This Immediate Jeopardy began on 10/5/25 at 5:30 PM when V7, Certified Nursing Assistant (CNA), witnessed R3 sexually abusing R2. The Facility did not report or investigate this, and no interventions were put in place to protect R2 from R3. The following day, on 10/6/25 at approximately 9:00 AM, R3 entered R2's room and sexually abused R3 again. V1, Administrator, was notified of the Immediate Jeopardy on 10/17/25 at 12:02 PM. The surveyors confirmed through observation, interview and record review that the Immediate Jeopardy was removed on 10/17/25, but noncompliance remains at Level Two because additional time is needed to evaluate implementation and effectiveness of the removal plan.Findings include:On 10/16/25 at 1:30 PM, R2 was sleeping 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.
- Immediate jeopardy · Jcited before2025-05-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to assess and treat a change of condition for 1 of 3 residents (R2) reviewed for change of condition. This failure resulted in R2 having a significant change in condition for several hours without interventions that ultimately required an emergency transfer in which her family called 911 and R2 experienced respiratory distress, was intubated en route to the hospital and placed on a mechanical ventilator. The Immediate Jeopardy began on 5/2/2025 when R2 began to experience respiratory/breathing issues and was not sent to the hospital in a timely manner. On 5/8/2025 at 12:43 PM, V1, Administrator, V2, Director of Nursing (DON), V3, Assistant Director of Nursing (ADON), V17, Regional Nurse Consultant/ VP Clinical Services and V18, RDO/CEO (Regional Director of Operations) and CEO were notified of the Immediate Jeopardy. The surveyor confirmed by observations, record review and interview, that the Immediate Jeopardy was removed on 5/9/2025 but non-compliance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Immediate jeopardy · J2024-01-31 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect residents from employee misappropriation of resident funds and exploitation for one of 7 residents (R51) reviewed for misappropriation of resident property in the sample of 42. This failure resulted in an Immediate Jeopardy when V22, Certified Nursing Assistant, (CNA), began using R51's debit card without his permission on March 2, 2023, accruing more than $11,000.00 in charges. When R51 became aware, he was upset and worried about taking care of future expenses and needs. The Immediate Jeopardy began on 3/02/23, when V22 began using R51's debit card without R51's permission. On 1/26/24, at 4:00 PM, V1, Administrator, V3, Assistant Director of Nursing (ADON), and V47, Registered Nurse, RN, were notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 1/29/24, but remains at Level Two because additional time is needed to evaluate the implementation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-10-21 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the Facility failed to follow its abuse policy in preventing, reporting and investigating allegations of abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 being sexually abused on 10/6/25 after previous allegation was not reported or investigated and no interventions were put in place to prevent further abuse.Findings include:On 10/16/25 at 1:30 PM, R2 was sleeping in bed in her room on a specialty mattress with a fall mat to the right side of her bed. R2 did not respond when spoken to. On 10/15/25 at 11:41 AM, V6, Certified Nursing Assistant (CNA), stated she was doing rounds on the hall and noticed R3 was in R2's room and was trying to get in bed with R2. R2 is non-verbal and cannot consent to sexual relations.On 10/15/25 at 2:10 PM, V7, CNA, stated on 10/5/25 around 5:30 or 6:00 PM, R2 was sitting in her reclining wheelchair in the dining room with her legs in the air. R3 was in his wheelchair sitting next to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-10-21 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to investigate an allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in witnessed sexual abuse on R2 by R3 the day after a sexual abuse allegation for the same two individuals was not thoroughly investigated.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and generalized anxiety disorder.R3's MDS dated [DATE] documented R3 was cognitively intact and ambulated via wheelchair.R3's Care Plan initiated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited beforedisputed · IDR2025-10-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to provide adequate supervision following an allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R3 entering R2's room without staff supervision and sexually abusing R2.Findings include:1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.On 10/16/25 at 1:30 PM, R2 was sleeping in bed in her room on a specialty mattress with a fall mat to the right side of her bed. R2 did not respond to verbal stimuli. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-02-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to monitor and assess blood sugar levels for residents with diabetes, for 1 of 3 residents (R2) were reviewed for quality of care in the sample of 14. This failure resulted in R2 requiring emergency intervention for blood glucose level 24 and hospitalization. Findings include: R2's Face Sheet, undated, documents she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition. R2's Minimum Data Set (MDS) dated [DATE] documented that she was cognitively alert and oriented. R2 has an active diagnosis for diabetes. R2's Care Plan, dated 8/12/24, documents, Problem: I have a diagnosis of diabetes mellitus, which places me at risk for medical complications. The goal for this care plan documents, I will experience no medical complications related to their diabetes through the next review. Interventions for this care plan include HgbA1c (Hemoglobin A1c is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-02-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to implement interventions to address a significant weight loss for 1 of 3 residents (R2) who were reviewed for weight loss in a sample of 14. This failure resulted in R2 experiencing a significant weight loss of 20% over a four-month period. Findings include: R2's Face Sheet, undated, documents she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition. The R2 medical record did not document how the facility obtained R2's initial weight upon admission on [DATE]. R2's Care Plan, dated 8/12/2024, documents the problem: Adult failure to thrive related to anorexia. The goal for this care plan documents (R2) will not exhibit signs of malnutrition or dehydration. The interventions for this care plan include assess for dehydration (dizziness on sitting/standing change in mental status, decreased urine output, concentrated urine, poor skin turgor,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-11-18 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to assess and provide medication for pain management for 2 of 3 residents (R4 and R7) reviewed for pain in the sample of 9. This failure resulted in R4 being in pain and R7 being unable to participate in therapy. Findings include: 1. On 11/13/2024 at 1:17 PM, R4 stated he did not receive pain medication for several days after admission. R4 stated, That was not good for me, as my pain was at an 8. R4 stated they were administered Tylenol, but that was not effective. R4's Medication Administration Record(MAR) History dated 11/1/2024-11-13-2024 documents Hydrocodone -acetaminophen -Schedule 2 table 5-325 Milligram (mg) administer 1 tablet every 8 hours as needed (prn). R4's MAR history documents start date 11/1/2024. R4's MAR history does not document R4 receiving pain medication until 11/8/2024. R4's Face sheet dated 10/29/2024 documents a diagnosis in part of low back pain, and pressure ulcer of sacral region stage 4. R4's progress notes dated 10/29/2024 at 10:51 AM document R4 arrived at the facility per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Hcited before2024-05-28 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to administer medications as ordered for residents (R1, R2, R3, R12) of 4 residents reviewed in a sample of 12. This failure resulted in R1 and R3 experiencing severe pain. Findings include: R1's face sheet, dated 5/23/24, documented that R1 was admitted on [DATE] with diagnoses of quadriplegia, hypertension, COPD (Chronic Obstructive Pulmonary Disease), spinal stenosis, intervertebral disk degeneration, osteoarthritis, and cirrhosis of the liver. R1's MDS (Minimum Data Set) dated 5/27/24 documented R1 is cognitively intact. On 5/23/24 at 6:40 AM, R1 stated that at the beginning of the week B hall did not have a nurse and that he did not receive any of his morning or noon medications. R1 stated that he went to the facility Administrator around 2 PM on this day and informed her that he had not received any medications all day. R1 stated that (V1) informed him she was aware of that hall not having a nurse and that the other nurses would administer 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.
- Actual harm · Gcited before2024-01-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe beverage serving temperatures to prevent thermal burns and adequate supervision to prevent falls for 3 of 9 residents (R60, R62, and R68) reviewed for accidents/hazards in the sample of 42. These failures resulted in R62 and R68 sustaining second degree abdominal burns and R60 falling and sustaining nasal fracture. Findings include: 1.R62's Face Sheet documents R62 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, essential primary hypertension, chronic obstructive pulmonary disease, type 2 diabetes mellitus with hyperglycemia, anxiety, encephalopathy, stage 3 chronic kidney disease, and obesity. R62's Minimum Data Set (MDS) dated [DATE] documented R62 was severely cognitively impaired and required substantial assistance rolling in bed and transferring. R62's 11/2/23 Care Plan documents R62 obtained a burn to her abdomen after spilling hot tea on her abdomen. The Facility's Incident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-01-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adequately assess and ensure a resident receiving continuous Gastrostomy tube (G-tube) feeding did not experience significant weight loss for 1 of 2 residents (R13) reviewed for nutrition in the sample of 42. This failure resulted in R13 having an insidious significant weight loss of 12 pounds in three months while receiving nutrition via G-tube. Findings include: R13's Face Sheet, undated, lists her diagnoses to include Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Aphasia following unspecified cerebrovascular disease, Dysphasia following cerebral infarction, and Gastrostomy status. R13's Minimum Data Set (MDS) dated [DATE] documents her weight as 198 even though her weight documented under vital signs in her electronic medical record (EMR) documents her weight as 189# on 11/4/23, which was the last weight documented before the MDS was done. According to the MDS, R13 has a feeding tube, and incorrectly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-10-18 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to refill medications timely for 1 of 3 (R2) residents reviewed for medication administration in a sample of 10. This failure resulted in R2 being admitted to the hospital for breakthrough seizure activity. Findings include: On 10/17/2023 at 11:30 AM, R2 stated that she was sent to the hospital because she was having seizures. She continued to state they didn't give her seizure medicine to her for at least a day or 2 and it sent her into full active seizures. She stated that they told her that they didn't have it and it was unacceptable to her. She continued to state that she was on top of her medication and it has happened before when they have run out of different medications for her. R2's Minimum Data Set, dated [DATE], documented that her cognition was intact. R2's Physicians order sheet, dated 10/2023, documented an order for Clonazepam 3 mg, oral, Twice A Day, by mouth twice a day. R2's Care Plan, dated 02/27/2023, documented, Approach: Medications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-03-17 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide resident bariatric equipment/bedside commode needed to promote resident dignity for 1 of 1 resident (R185) reviewed for accommodation of needs in a sample of 35. This failure resulted in R185 having feelings of embarrassment regarding being made to urinate/defecate in an adult incontinent brief instead of toileting. Findings include: R185's Undated Face Sheet, documents he was admitted to the facility on [DATE]. R185's Electronic Medical Record, dated 3/6/2023 at 2:14 PM documents R185 weighed 540.2 pounds and is 5 foot 11 inches tall. R185's admission Minimum Data Set (MDS) dated [DATE] documents R185 is alert, frequently incontinent of bladder and occasionally incontinent of bowel. R185's MDS documents R185 requires supervision with setup assistance for toileting. On 3/16/2023 at 10:00 AM R185 was sitting in his wheelchair. He stood up, leaned against his dresser and showed an incontinence brief under him. R185 stated, I have 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.
- Actual harm · Gcited before2023-03-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess, monitor, treat per standards of practice and implement interventions to prevent the formation and/or worsening of pressure ulcers for 2 of 9 residents (R68 and R282) reviewed for pressure ulcers in the sample of 35. This failure resulted in R282 developing two new unstageable pressure ulcers to bilateral heels. Findings include: 1. R282's Face Sheet, undated, documents diagnoses including Parkinson's disease, pressure ulcer of sacral region, unstageable, dysphagia, oropharyngeal phase, pressure ulcer of left hip, unstageable, mild protein calorie malnutrition, and dementia in other diseases classified elsewhere, severe, with agitation. R282's Minimum Data Set (MDS) dated [DATE] documented R282 was moderately cognitively impaired, required limited 1+ person assistance for bed mobility, required extensive 2+ person assistance with transfer, activity of walking activity did not occur over the previous 7-day period, and had one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-10-21 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to report allegation of sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including frontal lobe and executive function deficit following cerebral infarction and unspecified psychosis.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, dependent with mobility and ambulated by wheelchair.R2's Care Plan does not address risk of abuse and neglect.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, major depressive disorder, and generalized anxiety disorder.R3's MDS dated [DATE] documented R3 was cognitively intact and ambulated via wheelchair.R3's Care Plan initiated 9/29/25 documents R3 has a history of inappropriate contact with peers and staff.On 10/15/25 at 2:10 PM, V7, Certified Nursing Assistant (CNA), stated on 10/5/25 around…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-11 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify resident's representatives of a fall in 1 of 4 residents (R3) reviewed for accidents in the sample of 4. Findings include: 1.R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including osteoporosis, pain and dementia. V4, R3's Family, is listed as R3's Emergency Contact and Durable Power of Attorney. R3's Minimum Data Set (MDS) dated [DATE] documented R3 was severely cognitively impaired and required partial assistance with bed mobility and transfer. R3's Fall Report dated 5/27/25 documents R3 had an unwitnessed fall. R3's Progress Note dated 5/27/25 at 10:31 AM by V5, Licensed Practical Nurse (LPN), documents R3 was found on the floor with a hematoma (bruise) on the right side of (her head). R3's Progress Note dated 5/28/25 at 4:07 PM by V6, Social Services Director, documents V4, R3's family, was not notified of R3's fall, and it was determined that the contact number for V4 was incorrect. On 6/10/25 at 11:20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to completed physician's ordered wound care for 1 of 3 residents (R2) reviewed for wound care in the sample of 4. Findings include: 1. R2's Face Sheet documents R2 resides in the Facility with diagnoses including paraplegia, pressure ulcer, and acquired absence of both left and right leg below the knee. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, dependent for mobility, and had two pressure ulcers that were present on admission. R2's Care Plan dated 6/8/21 documents R2 is at risk for impaired skin integrity. R2's Care Plan dated 5/29/24 documents R2 has wounds to left thigh/buttock region and right thigh. R2's Wound Consultant Company Report dated 5/27/25 documents R2 had a wound to left posterior thigh measuring 17 cm (centimeters) x 8.9 cm x 0.3 cm. The previous treatment prescribed by V8, Wound Nurse Practitioner, was continued which consisted of cleansing with normal saline or wound cleanser, applying collagen and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to treat resident's pressure ulcers per physician's orders for 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 4. Findings include: 1.R2's Face Sheet documents R2 resides in the Facility with diagnoses including paraplegia, pressure ulcer, and acquired absence of both left and right leg below the knee. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, dependent for mobility, and had two pressure ulcers that were present on admission. R2's Care Plan dated 6/8/21 documents R2 is at risk for impaired skin integrity. R2's Care Plan dated 5/29/24 documents R2 has wounds to left thigh/buttock region and right thigh. R2's Wound Consultant Report dated 5/27/25 documents R2 had a Stage 3 pressure ulcer to left proximal thigh measuring 2.9 centimeters (cm) x 1.9 cm x 0.2 cm. The previous treatment prescribed by V8, Wound Nurse Practitioner, was continued which consisted of cleansing with normal saline or wound…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-14 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to report a hip fracture of unknown origin for 1 of 3 residents (R7) reviewed for abuse in the sample of 13. Findings include: 1-R7's Face Sheet documents R7 was admitted to the facility on [DATE] with diagnoses including quadriplegia, muscle contractures, protein calorie malnutrition, and dementia. R7's Minimum Data Set, dated [DATE] documented R7 was moderately cognitively impaired and required substantial/maximal assistance with bed mobility and transfer. R7's Progress Note dated 3/7/25 at 1:58 PM documents R7 experienced a change of condition and was sent to the hospital. R7's (Local Hospital) emergency room (ER) Records by V30, ER Physician, on 3/7/25 at 10:47 PM document, Nursing staff noticed abnormal movement of the knee. Imaging shows fracture of the distal femur. Orthopedic surgery please patient needs higher level of care where this traumatic injury can be managed. Unsure when patient's injury may have occurred, it may be why she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide tracheostomy care as ordered and appropriate tracheostomy supplies for 1 of 1 resident (R4) reviewed for Quality of Care in a sample of 13. Findings Include: R4's Face Sheet, undated, documents R4 was admitted [DATE] with a medical diagnosis of chronic respiratory failure with hypoxia. R4's Minimum Data Set (MDS) dated [DATE], documents R4 is cognitively intact, needs substantial/maximal assistance with personal and oral hygiene, and requires intermittent oxygen therapy, suctioning and tracheostomy (trach) care. R4's Care Plan does not address R4's tracheostomy needs. R4's Progress Note by V10, Licensed Practical Nurse (LPN), dated 3/5/25 at 4:50 AM, documents R4 was sent to hospital. R4 had pulled out trachea. On 3/11/25 at 12:50 PM, V10, LPN, stated she was rounding when she first saw R4's trach was removed. V10, LPN, stated she looked around the room from the trach that came out but couldn't find it. V10, LPN, stated she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-14 · tag F0712 — isolatedEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 physician visits were completed within 30 days of admission and at least every 60 days thereafter for 3 of 3 residents (R1, R2, R5) reviewed for physician visits in the sample of 13. Findings include: 1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, hypertension, and type 2 diabetes mellitus with diabetic chronic kidney disease. On 3/7/25 at 12:28 PM, V1, Administrator, stated she has no documentation to show R1 was seen by a physician during the first 30 days of admission. 2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, epilepsy, and intellectual disabilities. On 3/7/25 at 12:28 PM, V1 provided documentation that R2 was seen by V7, Physician, on 2/2/25, and stated that has been R2's only physician visit in the past six months. 3-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-02-27 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was scheduled in the facility for at least 8 consecutive hours a day, 7 days a week. This had the potential to affect all 99 residents who reside in the facility. Findings include: On 2/27/25 at 8:15 AM, V1, administrator, provided copies of nursing staff schedules for dates February 1 to February 27, 2025. On 2/1/25, 2/2/25, 2/3/25, 2/4/25, 2/7/25, 2/10/25, 2/14/25, 2/15/25, 2/16/25, 2/17/25, 2/18/25, 2/19/25, 2/20/25, 2/21/25, 2/24/25, and 2/25/25 there was no RN coverage for 8 consecutive hours. On 2/27/25 at 12:10 PM, V1 stated that she was aware there should be eight hours of consecutive RN coverage per day. She stated that they should be calling in an RN when this coverage is not present. V1 stated there are times when V2, director of nurses (DON) will come in, if there is no RN coverage. On 2/27/25 at 1:40 PM V1 confirmed the facility did not have a policy specific to RN coverage. The facility's Long-term Care facility Application for Medicare and Medicaid, dated 2/26/25, 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.
- Potential for harm · Fcited before2025-02-27 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store medication, label insulins vials, and discard expired medication. This has the potential to affect all 99 residents living in the facility. Findings include: 1. On [DATE] at 9:50 AM the facility's Medication Storage Room was inspected and contained the following: 1. 1 open bottle of Meclizine 12.5mg with expiration date [DATE]. 2. 1 open bottle of Meclizine 12.5mg with expiration date 9/2025. 3. 2 bottles of Meclizine 12.5mg with expiration date 2/2025. On [DATE] at 9:55 AM V6, Licensed Practical Nurse (LPN) stated that the Meclizine was open and in use. V6 confirmed that the medication was a stock medication and that it was expired and should be discarded. V6 stated that the medication can be used for anyone in the facility if they have an order. V6 stated that the insulin pen should have an open date. On [DATE] at 9:59 AM 400 hall Medication Cart was inspected. The medication cart contained the following: 4. 1 open…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-02-27 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to label and store foods appropriately, failed to wear hair restraints, perform hand hygiene in between glove changes and keep personal open drink containers away from where food was being prepared. This has the potential to affect all 99 residents living in the facility. Findings includes: 02/24/25 09:00 AM pork roast was thawing out on the bottom shelf in the refrigerator. Refrigerator door was slightly open and temperature was reading 43.4F. a tray of chocolate pudding cups were covered by not labeled and dated, V12, Dietary Manager was asked if it was pudding and she stated yes. On 02/25/2025 at 11:25 am, V14, Maintenance Director, with long dread locks, was not wearing a hair restraint of any kind, walked through the kitchen where food was being prepared on the stove top that was not covered and went through the break room door at the other end. On 02/25/2025 at 11:30 am there was an opened energy drink can and a tumbler, with a lid and straw sitting on the counter in the food preparation area. V12, Dietary manager the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 41 citations
- Potential for harm · Ecited before2025-02-27 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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 prevent the potential spread of infection by not utilizing Personal Protective Equipment (PPE) while providing direct care, as well as complete hand hygiene between glove changes for 5 of 5 residents (R52, R8, R45, R27 and R60) reviewed for Transmission Based Precautions (TBP) in the sample of 59. Findings include: On 2/24/2024 at approximately 9 AM, the B hall of the Facility was toured. Upon observation, there were no rooms with signage of TBP nor were there any Personal Protective Equipment (PPE) present. 1. The Facility's Matrix provided on 2/24/2025 documents R52 a pressure ulcer (open wound), catheter and a Gastroenteric tube (G tube- a tube in the stomach to deliver nourishment/medications). R52's Face sheet dated 2/25/2025 documents R52 has a pressure ulcer and a G-tube. On 2/24/2025 at 10:19 AM, V16, Wound Nurse, was observed exiting R52's room and stated she had just completed R52's dressing changes to her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-27 · tag F0926 — failed to keep the home smoke-free / fire-safe — patternHave policies on smoking.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide storage that locks for residents smoking materials, including vapes, lighters and tobacco and failed to provide supervision during smoking times for 8 of 8 (R32, R38, R68, R69, R76, R82, R148 and R149) residents reviewed for smoking. Findings include: 1. On 02/25/2025 at 10:00 am, R32 was outside of the facility, smoking. No staff was outside at this time. On 02/26/2025 at 1:40 PM, R32 was coming inside the facility from having a cigarette. R32 was asked where he stores his cigarettes and lighter when he is not smoking, he stated, In my pocket. We don't lock up our cigarettes and lighters. We don't have anywhere to lock them up so other residents can't get to them. R32's Smoking assessment, dated 10/17/2024, documented that he was independent with smoking. R32's MDS, dated [DATE], documented that his cognition was intact. R32's Physicians order sheet, dated 2/2025, documented diagnoses of Peripheral Vascular Disease and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the Facility failed to ensure blood sugar levels were documented for tracking, trending and monitoring of a chronic condition for 1 of 32 residents (R78) reviewed for medications, in the sample of 59. Findings include: 1. On 2/25/2025 at 8:30 AM, R78 stated she had issues with her insulin. R78 stated she did not receive her insulin shot at lunch on Sunday, 2/23/2025 and her blood sugar level was 189. R78 stated she told V11, Licensed Practical Nurse (LPN). On 2/25/2025 at approximately 8:45 AM, V11 checked R78's Medication Administration Record and stated it shows that R78 did receive her insulin at lunch on 2/23/2025. V11 stated R78 gets her blood sugar level checked 3 times on day shift (6 AM-6 PM) and has parameters depending on what the level is. V11 stated, Maybe it wasn't high enough to give (the insulin). V11 then looked to see if R78's blood sugar level was documented but V11 could not find the results. V11 then stated, The order wasn't in (the Electronic Medical Record). We had to modify the order so now there is a place to document it.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to perform complete incontinent care for 2 of 4 (R27, R94) residents reviewed for incontinent care, in a sample of 59. Findings include: 1. R94's Minimum Data Set (MDS), dated [DATE], documents that R94 requires assistance with toileting. It also documented that he was always incontinent of his bowels and bladder. On 2/25/2025 at 9:00 AM observed V7, Certified Nurse Assistant, (CNA), perform incontinent care. R94 was incontinent of urine. V7 assisted R94 into bed and then removed urine soiled pants and heavily soiled incontinent brief. V7 then using a wet wipe cleansed R94's penis wiping in a back-and-forth motion. R94 then using a wet wipe each side of R94's penis. V7 then assisted R94 with applying a dry brief. R94 did not cleanse R94's scrotum, inner thighs and buttocks. 2.V5, CNA, performed incontinent care on R27, and during care she cleansed R27's right groin, then took a new wipe cleansed R27's left groin and then took another wipe and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the Facility failed to monitor/document episodes of behaviors for which psychotropic medications were prescribed, as well as follow up on pharmacy recommendations for 1 of 3 residents (R83) reviewed for unnecessary medications in the sample of 59. Findings include: 1. R83's Behavior Tracking dated February 2025 documents it was initiated 10/17/2024 for Physical Aggression is completely blank. R83's Behavior Tracking dated February 2025 documents it was initiated 10/17/2024 for receiving psychotropic medications to decrease symptoms of anxiety is completely blank. The Facility's Psychotropic & Sedative/Hypnotic Utilization Form dated 12/1/2024-12/10/2024 documents R83 receives an Anxiolytic Lorazepam 0.5 milligrams (mg) ordered 11/5/2024. It documents it is given PRN (as needed) and a recommendation was sent. R83's Care Plan dated 10/17/2024 documents R83 receives psychotropic medications related to dementia and the goal is to remain free of drug related complications. It further documents, Consult pharmacy, MD (Medical Director) to consider…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-27 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the Facility failed to ensure preventative health vaccines such as Respiratory Syncytial Virus (RSV) and Pneumonia (PNU) were administered to those who gave consent and wished to receive them for 2 of 5 residents (R8 and R78), reviewed for immunizations, in the sample of 59. Findings include: 1. R8's RSV Vaccine Consent Form and Pneumococcal Vaccine Consent Form documents, I give consent and was signed by R8's Power of Attorney (POA) on 10/22/2024. The second pages of the Forms are not completed/blank. R8's Face sheet dated 2/25/2025 documents R8 has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). 2. On 2/25/2025 at 9:30 AM, R78 stated she was admitted to the Facility in October 2024. R78 stated she was asked about receiving the PNU vaccination, she wanted and agreed to receive it, but has not heard anything else about it. R78's Pneumococcal Vaccine Consent Form documents, I give consent and was signed by R78 on 10/23/2024. The second page of the Forms are not completed/blank. On 2/25/2025 at 10:15 AM, V3, Assistant Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-20 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to notify the physician of changes in condition related to weight loss and blood glucose readings for 1 of 3 residents (R2) reviewed for change in condition in the sample of 14. Findings include: R2's undated Face Sheet documents she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, vascular dementia, diabetes, and unspecified calorie protein malnutrition. R2's weight record, dated 9/12/24, documented her weighing 170 pounds. On 10/12/24, she weighed 168 pounds. On 10/28/24, she weighed 2 pounds. On 11/6/24, she weighed 152 pounds, and on 12/5/24, she weighed 136 pounds. These weights calculate a 20 % weight loss in three months from 9/ 2/24 to 12/5/24 and a 10.5 % weight loss over the last month from 11/6/24 to 12/5/24. There was no documentation in R2's medical record that V22, R2's Physician, was notified of R2's significant weight loss. On 2/13/25 at 11:25 AM, V2, Director of Nursing, DON, stated that once…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to locate and/or replace missing clothing for 1 of 1 resident reviewed for loss of property in the sample of 17. On 1/22/2025 at 1:40PM V19, R10's family member, stated Dad lost clothes, jackets, a brand-new pair of white leather shoes, hearing aids, and two blankets. I took him a blanket and the blanket disappeared. I took him another blanket and the next day that blanket was gone. It was unbelievable. On 1/22/2025 at 2:00PM V16, Social Services Director, stated I don't know anything about R10's missing clothes. I thought we found everything and returned it. On 1/22/2025 at 2:30PM V1, Administrator, stated I thought his items were found. I'm not sure. I don't think they filed a grievance. On 1/23/2025 at 2:00PM V19 stated We didn't get any missing items back from the facility. They have not contacted us for reimbursement either. On 1/23/2025 at 3:00PM V1 stated We have a grievance filled out for the missing items. A family member picked the items up, but I don't know who it was. Grievances for the past 3 months were asked for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure abuse did not occur for 1 of 3 residents (R9) reviewed for abuse in the sample of 17. Findings include: R9's Physician Order Sheet for January 2025 documents a diagnosis of aftercare following joint replacement surgery, acute osteomyelitis, left ankle and foot, bipolar disorder, anxiety disorder, type 2 diabetes, diabetes mellitus without complications, unspecified protein calorie malnutrition, morbid obesity due to excess calories, hyperlipidemia, gangrene, not elsewhere classified, chronic viral hepatitis, hyperglycemia, neuropathy, frost bite of the foot. R9's Minimum Data Set (MDS) dated [DATE] documents R9 was cognitively intact for decision making of activities of daily living. R9's Progress Notes dated 11/15/2024 at 8:00 PM, Resident and staff member arguing in dining room. Resident and staff member separated, and resident went to room. Resident feels safe. MD (Medical Doctor) notified. On 1/22/2025 at 2:43 PM, R9 stated, Last month that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-24 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to initiate and thoroughly investigate alleged violations of abuse for 1 of 3 residents (R9) reviewed for abuse in the sample of 17 Findings include: On 1/22/2025 at 2:43 PM, R9 stated, Last month that Dietary Aid (V10) was foul to me, and I mean foul. She had an attitude, and she was coming at me, screaming at me, calling me names, telling me to shut up. She kept coming and coming and then she picked up a glass and was going to throw it in my face, but staff stopped her. I should not have to worry about staff trying to hurt me. No staff should try and hurt anybody living here. At that time, I was fearful. I know I have an attention deficit, and some issues but no staff should be trying to hurt anybody. She no longer works here. They fired her. On 1/22/2025 at 3:03 PM, V12, Licensed Practical Nurse (LPN) stated, I remember the Dietary Aid was screaming at (V9) and they were both upset, and I told her to clock out and go home and she ignored me. I found out later she had quit that same day. I don't remember anything else. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview and Record Review, the facility failed to administer ordered medications to 1 of 1 resident reviewed for medications in the sample of 17. R2's Facesheet documents an admission date of 3/2/2024. Diagnosis include Osteomyelitis, Gastroesophageal Reflux Disease, Peripheral Vascular Disease, Acquired absence of other right toe(s), Chronic Kidney Disease, Acute Embolism and Thrombosis of unspecified deep veins of left lower extremity, Type 2 Diabetes. R2's Minimum Data Set, MDS, dated [DATE] documents R2 has no cognitive deficits. R2's Care Plan updated 10/24/2024 documents I have chronic pain related to Gastroesophageal Reflux Disease, Neuropathy, and Idiopathic gout. Interventions include: Report to Nurse my complaints of pain or requests for pain treatment. Pain Assessments quarterly and as needed. R2's order sheet dated 9/12/2024 documents oxycodone - Schedule II tablet; 5 mg; amount: 1 tab; oral Twice A Day. Open ended. 7:00AM-10:00AM, 4:00PM-6:00PM. R2's medication administration sheets dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-10 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide medication as ordered by the Physician. This applies to 1 resident (R1) of three reviewed for medication administration in a sample of three. Findings include: R1's medical diagnosis from the electronic medical record documents R1 as an [AGE] year-old with diagnoses to include Vascular Dementia with severe agitation. On 01/09/2025 at 12:29 PM V2 (Director of Nursing) stated On the second, (01/02/2024) in the afternoon (R1) was having a meltdown. He was striking staff and asking who we are going to murder. The nurse asked me to assist her with drawing up his PRN (as needed) medication. It was an intense situation. Instead of going to the MAR (medication administration record) I asked her what dose of Haldol he was receiving. Her response was 2ml (milliliters). I went to the med cart drew up the 2ml and gave it. It calmed him down eventually. He had a seat and kept busy with adjusting and messing with a wheelchair. There was no drowsiness or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
-- Based on observation, interview, and record review, the facility failed to implement fall interventions for 1 of 3 residents (R2 ) reviewed for falls in the sample of 9. Findings include: R2's progress notes, dated 11/1/2024 at 6:16 pm, document that R2 arrived at the facility by ambulance on a stretcher. The notes document that R2 is alert and orientated x4. R2 uses a manual lift with all transfers, is able to let needs be known, has no skin issues, and has a history of CVA. The notes document weakness on the left side due to the previous stroke. R2's progress notes dated 11/2/2024 at 6:54 pm document the Certified Nursing Assistant (CNA) notifying the nurse resident was lying on the ground next to his bed. R2's progress notes document that the nurse observed the resident lying on the left side of the floor with his left hip propped up on the bedside table. R2's notes document resident stated was trying to pick up his phone off the floor when he lost his balance on his weaker side (left). R2's notes document that upon inspection, there was no bleeding. The right hip has some…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-18 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
- Based on observation interviews and record reviews, the facility failed to provide medications as ordered for 2 of 3 residents (R4 and R7) who were reviewed for medications in the sample of 9. Findings include: 1. On 11/13/2024 at 1:17 PM, R4 stated he did not receive pain medication for several days after admission. R4 stated, That was not good for me, as my pain was at an 8. R4 stated the was administered Tylenol but that was not effective. R4's Medication Administration Record (MAR) History dated 11/1/2024-11-13-2024 documents Hydrocodone -acetaminophen -Schedule 2 table 5-325 Milligram (mg). Administer 1 tablet every 8 hours as needed (prn). R4's MAR history documents stator date 11/1/2024. R4's MAR history does not document R4 receiving pain medication until 11/8/2024. R4's Face sheet dated 10/29/2024 documents a diagnosis in part of low back pain, and pressure ulcer of sacral region stage 4. R4's progress notes dated 10/29/2024 at 10:51 AM document R4 arrived at the facility per ambulance. R4's progress notes dated 10/30/2024 at 1:53 PM document a call placed to the hospital…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-25 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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 - A-Based on observation, interview, and record review the Facility failed to provide additional nourishment when ordered for 1 of 3 residents (R15) reviewed for weight loss in the sample of 20. Findings include: R15's Physician Order Sheet (POS) for October 2024 documents a diagnosis of vascular dementia, severe, with agitation; unspecified protein-calorie malnutrition; cerebral infarction, unspecified; constipation, unspecified; and cerebral atherosclerosis. Ensure( protein shake) at breakfast, lunch, and dinner. R15's Minimum Data Set, dated [DATE] documents she is severely impaired for cognition for activities of daily living and decision making. R15's Care Plan documents, Problem: I am at risk for alteration in nutrition r/t (related to) vascular dementia. R15's weight on 10/12/2024 at 2:43 PM documented that R15 weighed 76 pounds, and her BMI (Body mass index) was 15.88. R15's weight on 7/5/2024 at 8:55 AM was 83 lbs (pounds), and her BMI was documented as 16.93. (-8.43 difference, less than 10% for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 implement current interventions and initiate progressive interventions to prevent falls for 4 of 4 (R1, R2, R4, R5) residents reviewed for falls in the sample of 5. Findings include: 1. On 10/03/2024 at 10:40 AM, R2 was observed sitting in the dining room in his wheelchair. R2 states that he had a fall on 09/06/2024 when he was in the bathroom. R2 states he was trying to pull down his pants, and he fell forward and hit his head on the bathtub. R2 states he was sent to the emergency room and received 6 stitches by his right eye. R2 states that he is pretty independent, gets up on his own, and goes to the bathroom. R2 denies any other recent falls. R2 states that he knows how to use his call light when he needs help, has learned his lesson the hard way, and always wears shoes when he gets up. On 10/03/2024 at 10:47 AM, a Call don't fall sign was observed on R2's wall, along with a sign stating transfer 1 assist on R2's side wall. There…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-04 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have pain medication available as ordered for one of three residents (R3) reviewed for pain in the sample of 5. This resulted in R3 not receiving his narcotic pain medication as ordered for 10 out of 30 days in September 2024. Findings include: R3's undated Face Sheet documents that R3 was admitted on [DATE] with diagnoses that include Stable Burst Fracture of First Lumbar Vertebra, Unstable Burst Fracture of Second Lumbar Vertebra, Initial Encounter for Closed Fracture, pain, and Unspecified Osteoarthritis. R3's Minimum Data Set (MDS) dated [DATE] documents that R3 is alert and oriented and has moderate difficulty hearing. R3's Care Plan dated 4/7/23 documents: I have potential for pain/discomfort r/t (related to) dx (diagnosis) of non-infective gastroenteritis and colitis, unspecified osteoarthritis, stable burst fracture of first lumbar vertebrae, unstable burst fracture of 2nd lumbar vertebrae and unspecified pain. The goal for this…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-06 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - Based on the interview and record review, the Facility failed to document necessary assessments of wound conditions per its policy, complete treatments as prescribed by a physician, and ensure the resident was assessed in a timely manner after a referral for one of three residents (R2) reviewed for wound management in the sample of 8. Findings include: On 8/29/2024 at 9:05 AM, R2 stated he had been at the Facility for a month and had not been seen by a doctor about his foot wound. R2 stated his foot bandage was changed on 8/28/2024, but prior to that, it had not been changed since the Thursday before. R2 stated his wound should be getting better, but it is not. R2's Face Sheet dated 9/3/2024 documents that R2 has a diagnosis of Stiff Man Syndrome, Cerebral Palsy, Tinea Pedis (fungal infection), Cellulitis (unspecified part of limb), and an open foot wound. It further documents that R2 was admitted to the facility on [DATE]. R2's Care Plan dated 7/20/2024 does not address the monitoring of R2's foot wound but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-06 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - Based on observation, interview, and record review, the Facility failed to ensure medications were readily available for administration per physician's orders to ensure residents' highest well-being, comfort, and pain control for 3 of 7 residents (R1, R4, and R8) reviewed for medications in the sample of 8. Findings include: 1. On 8/29/2024 at 10:00 AM, R1 stated she was admitted to the Facility after having a back surgery. R1 stated she went without her pain and sleep medications. R1 stated she had staff tell her several different stories about why she did not receive her medications. R1 stated a nurse (unknown) asked R1 if R1 had called the pharmacy about her medication. R1 stated, I thought they were supposed to do that. R1 stated it finally got straightened out when the facility staff got a handwritten prescription for the doctor. R1 stated she did experience quite a lot of pain. R1 stated she went from Tuesday (8/20/2024) until Friday (8/23/2024) without her pain and sleep pills. R1's Facesheet dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-06 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to ensure medications were readily available for administration per physician's orders for 3 of 7 residents (R1, R4, and R8) reviewed for medications in the sample of 8. Findings include: 1. On 8/29/2024 at 10:00 AM, R1 stated she was admitted to the Facility after having a back surgery. R1 stated she went without her pain and sleep medications. R1 stated she had staff tell her several different stories about why she did not receive her medications. R1 stated a nurse (unknown) asked R1 if R1 had called the pharmacy about her medication. R1 stated, I thought they were supposed to do that. R1 stated it finally got straightened out when the facility staff got a handwritten prescription for the doctor. R1 stated she did experience quite a lot of pain. R1 stated she went from Tuesday (8/20/2024) until Friday (8/23/2024) without her pain and sleep pills. R1's Facesheet dated 9/5/2024 documents R1 had a diagnosis of acute pain due to trauma as well…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-08-15 · tag F0550 — failed to protect resident dignity and rights — widespreadHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to allow phone access to facility and residents for 2 of 3 residents reviewed for resident rights. This has the potential to affect all 86 residents in the facility. Findings include: R3's baseline Care Plan, dated 7/9/2024, documents that R3 was admitted to the facility on [DATE] for end of life care. On 7/24/2024 at 7:36 PM surveyor called facility number. Telephone rang 6 times and then went to busy signal; phone was not answered. On 7/24/2024 at 7:45 PM surveyor called the facility phone. Rang 5 times and then went to busy signal. staff did not answer the phone. On 7/25/2024 at 8:00 PM surveyor called facility phone. Telephone rang 5 times. Transferred to answering service. On 7/25/2024 at 9:15 PM surveyor called facility phone. Telephone rang 5 times. Then busy signal. On 7/24/2024 at 12:04PM V10, (R1's wife) stated staff do not answer the phone of an evening. V10 stated there is a camera in her husband's room and if she comes to the facility after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure wound treatments were completed, physician orders followed and residents repositioned timely for 1 of 3 (R2) residents reviewed for pressure ulcers. Findings include: R2's Care Plan, dated 6/15/2024, documents Last Reviewed/Revised: 07/25/2024 02:44 PM. PROBLEM: I have acquired an unstageable pressure ulcer to right posterior thigh My comorbidities include malnutrition and bed mobility. Approach: Administer treatments as ordered and monitor for effectiveness. APPROACH: Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (physician). APPROACH: Follow facility protocols for the prevention/treatment of skin breakdown. APPROACH: Monitor/document/report to MD PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-15 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the Facility failed to ensure pain was assessed, recognizing the onset, presence, and duration of pain, and assessing the characteristics of the pain and provide pain management for 1 of 3 residents (R3) reviewed for pain. This resulted in R3 experiencing pain during dying process. Findings include: R3's Baseline Care Plan, dated 7/9/2024, does not address R3's pain. R3's Pain Assessment, dated 7/9/204, documents that R3 was experiencing pain. Review of R3's Vitals report and no vitals noted. On 7/31/2024 R3's pain assessments requested. As of 8/13/2024 12:00 PM the facility had not provided assessments. R3's Hospice Progress Notes, dated 7/11/2024 at 11:29 PM, Worsening Symptoms Call Back for Additional Questions or Concerns, Call Back for Any New, Change or Worsening Symptoms 2320 - call from (V19) at (facility) asking about scheduling the morphine and lorazepam Asked when last doses were given - both were administered at 2130. She did not know when previous doses were given. States family is concerned over muscle spasms. This RN encouraged…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-28 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to provide sufficient staffing on 5/20/24 for 4 of 6 (R1, R2, R3, R4) residents sampled for medications and blood glucose testing. Findings include: The facility daily assignment schedule dated 5/20/24 documented a licensed nurse assigned to A hall and a licensed nurse assigned to C hall. The facility daily assignment schedule dated 5/20/24 did not document a licensed nurse assigned to the B hall. On 5/23/24 at 6:10 AM, V5, CNA (Certified Nurse Assistant) stated the B hall did not have a nurse for the entire day shift on 5/20/24. On 5/23/24 at 6:15 AM, V6, CNA stated she worked on 5/20/24 and that there was no nurse on the B hall that day. On 5/23/24 at 6:30 AM, V7, CNA stated she was assigned to the B hall on 5/20/24 and there was no nurse assigned to the B hall. V7 stated she went to the other two floor nurses on duty to request medications for some of the B hall residents and that the two floor nurses informed her that they were not able to pass the B hall medications and informed her to go to the facility Social Worker for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall interventions and precautions were in place for 1 of 3 residents (R7) reviewed for falls in a sample of 7. Findings include: R7's Face Sheet, with an admission date of 02/20/24, documented that R7 had diagnoses of dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic obstructive pulmonary disease (COPD), hypertension (HTN), Peripheral vascular disease, and Rhabdomyolysis. R7's Minimum Data Set (MDS), dated [DATE], documented that R7 was cognitively intact, and she required supervision or touching assistance with part of dressing, transfer, and walking. R7's Care Plan, with an admission date of 02/20/24, documented, Problem: R7 is at risk for falls due to rhabdomyolysis and history of falls. Goal: Resident will be free of falls. Approaches are but not limited to Bed alarm to bed when in it, educate and encourage resident to use call light for assistance.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, and distributed in a manner that prevents potential foodborne illness. This has the potential to affect all 89 residents living in the Facility. Findings include: On 1/21/24 at 8:05 AM in the dry storage room there was a stack of boxes stored directly on the floor, including two boxes of potato chips with a box of saltine crackers on top. There was a box of Styrofoam cups, and a box of food storage covers on the highest shelves that came within 12 inches of the ceiling. The three-door freezer had a cardboard box of frozen uncooked beef that had been placed directly on top of a cardboard box of broccoli florets. The box of beef had a label stating, Uncooked - Must Be Cooked to 160°F (Fahrenheit). On 1/21/24 at 8:12 AM the walk-in refrigerator contained four plastic containers labeled jello that were dated 1/10 with a use by date of 1/17. There was a plastic bag with an item that resembled raw bacon with no label or date. On 1/21/24 at 8:14 AM on top of the microwave there was a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-31 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure an Infection Preventionist has the professional training and qualifications to perform in this role. This has the potential to affect all 89 residents living in the Facility. Findings include: On 1/21/2024 at 9:15AM V1, Administrator, stated V28, Certified Nursing Assistant, CNA, is the Infection Control Preventionist. On 1/30/2024 at 9:45AM V28 stated I really don't remember the training. If I have questions, I go to V18, Registered Nurse, and (V56, Regional Nurse). I do not have an associate degree. I am a Certified Nursing Assistant. I do handwashing and peri care training. I do not do infection control. (V3, Assistant Director of Nursing, ADON), does training on infection control. On 1/30/2024 at 10:25AM V18, Registered Nurse, stated I did the Infection Control training years ago. I have retired since then. I know I do not have a certificate. If (V28) is not here, infection control would refer to me. I usually work three days per week. On 1/30/2024 at 9:45AM V28 provided a certificate dated 3/2/2023…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-31 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse for 6 of 7 residents (R10, R49, R50, R51, R62, R293) reviewed for abuse in the sample of 42. Findings include: 1.The Facility's Incident Initial Report, dated 1/6/24, documented, On 1/6/24 at 740p (7:40 PM) Nurse contacted Administrator and advised that the alleged victim was coming down C hall and tried getting around the alleged perpetrator and accidentally bumped into the victim. Nurse immediately separated the residents. Nurse assessed both residents in their rooms. No injuries noted. MD/POA (Medical Doctor/Power of Attorney) contacted. Police contacted. Investigation initiated. R62's Late Entry Progress Note, dated 1/7/24, by V16, Registered Nurse (RN), on 1/6/24 at 7:30 PM documented, Other res (resident) was attempting to propel self in Wc (wheelchair) by this res. This res began to call other res names and then started to slap other res left arm. Res immediately separated. Res denies pain. No inj (injuries) noted. On 1/24/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-31 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
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 the resident's care plan to ensure proper placement of gastrostomy tubes (g-tubes) and ensure the correct enteral formula is provided for residents with g-tubes for 1 of 2 residents (R13) reviewed for g-tubes in the sample of 42. Findings include: On 1/21/24 at 12:21 PM R13 was lying in her bed with her tube feeding infusing at 65 ml/hr (milliliter per hour) per her g-tube. There was no label documenting what formula is being given per g-tube or when current formula was initially started for R13's tube feeding that was infusing per g-tube. The bag containing the tube feeding formula was a generic bag that formula was added to, not a labeled formula container. There was no documentation on the bag with time or date the tube feeding formula was hung, name of resident, or what formula was contained in the bag. On 1/23/24 at 3:55 PM a bag of tube feeding formula was infusing per R13's g-tube with the date and time of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-12-05 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to store medication properly for 6 of 7 residents (R2, R4, R5, R6, R7, R8) reviewed for medication storage in a sample of 8. Findings include: 1. On 12/4/2023 at 8:42 AM a medication cup with a hydroxychloroquine 200 milligram (mg) pill was on R2's table. R2 was sitting in her chair with the cup, with the hydroxychloroquine, within reach. R2's Physician orders (POS), documents 9/10/23 hydroxychloroquine 200 mg, 1 tab oral once a day 7:00 AM-10:00 AM. The order does not document leave at bedside or resident to self-administer. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 has moderate cognitive impairment. On 12/4/2023 at 12:40 PM V4, Certified Nurse's Aide, CNA, stated that R2 is alert, able to answer questions appropriately and able to verbalize needs. On 12/4/2023 at 8:42 AM R2 stated that the nurse gave her the medication and left the room. R2 stated that the medication was left so that she could take it when she was ready.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation and record review, the facility failed to provide incontinent care per current standards of practice to prevent Urinary Tract Infections (UTI) for 1 of 3 (R2) residents reviewed for UTI's in the sample of 3. Findings include: On 11/22/23 at 8:20 AM, incontinent care was observed on R2 with V6, CNA (Certified Nurse's Assistant) and V7, CNA, with the following noted: V6, cleaned the front of R2's inner pubic area in an up and down motion with a wipe, then without changing gloves, got a clean washcloth and began to wash the R2's anterior pubic area again. Once done with the anterior pubic area, R2 was turned onto his left side, V6 changed her gloves but did not perform hand hygiene between glove changes. V6, then cleaned R2's buttocks and thighs. R2 was then turned onto his left side and incontinent care was performed, V6 changed her gloves approximately 4 times and did not perform hand hygiene between glove changes. R2's Face Sheet, undated, documents R2 has the following diagnoses: UTI, Acute Cystitis with Hematuria and Neuromuscular Dysfunction of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-11-02 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to enforce work restrictions for employees that were positive for COVID-19 to aid in the prevention/progression of COVID-19. This failure has the potential to affect all 90 residents residing in the facility. Findings include: On 11/1/23 and 11/2/23, R4, R8 and R9, were observed in their rooms on isolation for COVID-19. The facility Line List for COVID-19 Outbreaks in Long Term Care Facilities, documents the first resident tested positive for COVID on 10/12/23, which began to place the facility in outbreak status. The first employee tested positive for COVID-19 on 10/13/23. On 10/19/23, V11, Certified Nurse's Assistant (CNA), was having body aches and a sore throat. A COVID-19 test was performed and was positive for COVID-19. The Line Listing continues to show that as of 10/30/23, residents and staff were continuing to test positive for COVID-19, causing the facility to remain in an outbreak status. As of 10/31/23, there have been 42 residents and 18 staff members test positive for COVID-19. Three residents have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-02 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent visitor to resident mental abuse for 1 of 6 residents (R1) reviewed for abuse in the sample of 9. Findings include: The facility Abuse Investigation was reviewed with the following noted: Initial Report, dated 9/7/23, documents that V8, R7's Husband, videotaped R1 while she was in her room having behaviors. V8 then began showing the videotape to other family members in the dining room. Final Report, undated, documents the Administrator and clinical team informed V8, R7's Husband, that he could not tape other residents. V8 immediately deleted the video. The police were contacted and notified V8 that if this happened again, he would not be able to return to the facility. V8 agreed to follow the facility rules. V8's wife, R7, shares a room with R1 and was moved to a different room. V6, Housekeeping, written statement, dated 9/7/23 at 12:34 PM, documents V6 went to tell V8 that they were moving R7, upon doing so she witnessed V8 showing a video of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-05 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the Facility failed to answer call lights in a timely manner for 3 of 3(R1, R2, R3) residents reviewed for call lights in the sample of 12. Findings include: The Facility's Resident Council Meeting Minutes dated 7/5/23 document, Residents complained that their call lights are on for longer than 15 minutes at times. The Facility's Resident Council Meeting Minutes dated 8/1/23 document, Residents complained about being short CNA's (Certified Nursing Assistants) some days and having to wait longer. The Facility's Resident Council Meeting Minutes dated 9/5/23 document, Residents complained about having to wait for help longer (with call light on). R11's Facility Grievance Form dated 6/26/23 documents, Resident stated that on 6/25 he had his call light on for over an hour. The Recommendations/Action Taken was CNAs were in-serviced on timely answering of call lights. On 10/3/23 at 10:40 AM, R2 stated it took staff 30 minutes to respond to his call light the night before. On 10/3/23 at 12:00 PM, R3 stated the call lights are slow to be answered. He…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-05 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the Facility failed to ensure a safe, comfortable, homelike environment for 2 of 3 residents (R2, R4) reviewed for physical environment in the sample of 12. Findings include: On 10/3/23 at 9:53 AM, the D Unit Hallway had an oxygen tank on the floor, a linen cart, a water cooler on a cart, two meal trays on a cart, a bedside table, and two chairs. There was a bottle of bleach spray, a pair of gloves, and a tennis ball placed on the handrail. On 10/3/23 at 9:56 AM, the sides of the C Unit Hallway were lined with a bedside commode, a treatment cart, a linen cart, a sit to stand device, a dining cart, two isolation bins, a specialty wheelchair with a mechanical sling lift and cushion on top, two bedside tables, two chairs, and a regular wheelchair with foot pedals and a hairbrush on top. There was also a plastic glass with water that had been placed on the handrail. On 10/3/23 at 10:01 AM, V2, Director of Nursing (DON), moved the dining cart from one side of the hall to the other side to create a more direct pathway. On 10/3/23 at 10:02 AM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer medication to a newly admitted resident for 1(R2) of 10 residents in the sample of 12. Findings include: R2's Face sheet documents, an admission date of 9/26/2023 at 2:31PM. Diagnosis include Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, Subsequent Encounter Unspecified Fracture of Unspecified Lumbar Vertebra, Subsequent Encounter for Fracture with routine healing. Gastroesophageal Reflux Disease, Bipolar Disorder. R2's MDS dated [DATE] documents, R2 has no cognitive impairments. R2's Minimum Data Sheet, MDS not completed due to new admission status. R2's care plan dated 9/29/2023 documents, Problem: I am on antipsychotic medications related to my diagnosis of bipolar disorder (Latuda and quetiapine). R2's care plan dated 9/29/2023 documents I am currently on antidepressant medication related to my diagnosis of depression (sertraline). R2's order sheet dated 9/26/2023 documents, Alprazolam 0.25mg…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-19 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based observation, interview and record review the facility failed to ensure the facility was clean, comfortable, and homelike for 5 of 5 residents (R7, R8, R16, R17, R19) reviewed for homelike environment in the sample of 20. Findings include: 1.On 9/9/2023 at 10:50 PM, on the D-hall there was a strong pervasive odor of feces and urine that was very overpowering. 2. On 9/9/2023 at 10:49 PM, R8 was not in his room. Dried feces were on the floor of his room, and on his bed. The smear of feces on the bedsheet was approximately 4 inches long. The room smelled strong of feces and urine. On 9/9/2023 at 10:55 PM, R8 was not in his room but his roommate R16 was sitting on the bed moaning. R16 had a brown ring around his sheet and his diaper was soaking wet and saturated. R8's bed had dried feces on the bed sheet; an area the size of a softball. The floor also had dried feces on it. R16 was not able to communicate. There was a pervasive smell of bowel movement and urine. 3.On 0/9/2023 at 10:58 PM, R7's urinal was sitting on his bedstand and was full of urine. On 9/9/2023 at 11:00 PM, R7…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-19 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to assist residents with hygiene and incontinent/toileting care for 4 of 4 residents (R7, R8, R9, R16) reviewed for assistance with activities of daily living (ADLs) in the sample of 20. Findings include: On 9/9/2023 at 10:40 PM, there was no Certified Nurse's Aide (CNA) working on the D-hall. On 9/9/2023 at 10:43 PM, V10, Licensed Practical Nurse (LPN) stated, I am the only one working this hall tonight, there is no CNA only me and I am doing the best I can do. I am passing out medications right now. On 9/9/2023 at 10:45 PM, the facility's staffing schedules were reviewed, and no CNA was documented as working on the D hall. There was a name that was crossed off. On 9/9/2023 at 12:46 AM, V11, CNA stated she was working the A hall but there was no CNA this evening working the D hall. V11 stated she thinks there was a call off but no replacement. 2. On 9/9/2023 at 10:48 PM, R7 had a urinal sitting on his bedstand that was full of urine. On 9/9/2023 at 10:49 PM, R7 stated, (R8) likes to walk around naked and he will…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-17 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Facility failures resulted in two deficient practice statements. A. Based on observation, interview, and record review, the Facility failed to wear required personal protective equipment (PPE) and follow infection control precautions to prevent the spread of infectious disease. This has the potential to affect all 82 residents living in the Facility. B. Based on observation, interview, and record review, the facility failed to perform hand hygiene during incontinent/catheter care to prevent the spread of infection for one of 5 residents (R184) reviewed for infection control practices in the sample of 35. Findings include: A. R51's Face Sheet documents diagnoses including type 2 diabetes mellitus with diabetic neuropathy, diffuse large B-cell lymphoma, ventricular tachycardia, essential (primary) hypertension, unspecified atrial fibrillation, anxiety disorder, unspecified, and ulcerative colitis, unspecified, without complications. R51's Laboratory Report completed 2/8/23 documents C. Difficile (Clostridium difficile) Cytotoxin test result was Out of Range/H (High). R51's Physician…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to develop and implement progressive interventions to prevent falls for 3 of 7 residents (R73, R78, and R283) reviewed for falls in the sample of 35. Findings include: 1. R73's Face Sheet documents diagnoses including discitis, unspecified lumbar region, low back pain, repeated falls, syncope and collapse, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R73's Minimum Data Set (MDS) dated [DATE] documents R73 was cognitively intact, required limited one person assistance for bed mobility and transfer, and the activity of walking did not occur during the previous 7-day period. R73's Fall Risk assessment dated [DATE] documented R73 was at risk for falls. R73's Progress Note dated 12/25/22 at 9:50 AM documents, Resident was found on the floor next to his bed. He said that he…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-17 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide incontinent care/catheter care in a manner that prevents urinary tract infection for 1 of 5 residents (R184) reviewed for incontinent care/urinary tract infections in the sample of 35. Findings include: R184's Face Sheet, undated, documents R184 has a diagnosis of Kidney Failure. R184's Hospital records document, prior to admission to the facility, she was hospitalized from [DATE] to 2/28/23 with diagnoses to include Acute Kidney Injury and Urinary Tract Infection. R184's Minimum Data Set (MDS), dated [DATE], documents R184 requires extensive assistance from staff with toileting and hygiene. On 3/14/23 at 9:45 AM, R184 was sitting in her wheelchair. R184 stated they (staff) won't help her. R184 stated, I am sitting in poop. I put on my call light 30 minutes ago and told them I needed changed. R184 stated that staff told her that they would be right back. R184 stated, I haven't seen anyone yet. At 10:19 AM V6 (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.
“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.
“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$399,548 in federal fines across 8 penalties.
- $39,950 — penalty dated 2026-02-11
- $158,110 — penalty dated 2025-10-21
- $43,729 — penalty dated 2025-05-09
- $51,307 — penalty dated 2025-02-20
- $11,485 — penalty dated 2024-10-04
- $46,715 — penalty dated 2024-04-29
- $25,186 — penalty dated 2024-01-31
- $23,066 — penalty dated 2023-10-18
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 EVERCARE SKILLED NURSING — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.1 | -0.1 vs chain |
| Health inspection | 1 of 5 | 1.6 | -0.6 vs chain |
| Staffing | 1 of 5 | 1.0 | ≈ chain avg |
| Quality measures | 2 of 5 | 1.9 | +0.1 vs chain |
The other 7 homes this chain runs (chain average 1.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ROSENBLATT, YEHUDA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/13/2025 |
| WEINBERGER, SHMUEL | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 01/13/2025 |
| EU SNF HOLDINGS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/13/2025 |
| AMPADU, CHARLES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2024 |
| HULTS, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2024 |
| RIXIE, TERESA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2024 |
| DAVID A BERKOWITZ DELTA TRUST | Organization | ADP OF THE SNF | since 07/01/2024 |
| RKS HOLDINGS LLC | Organization | ADP OF THE SNF | since 01/13/2025 |
| RKS MANAGER LLC | Organization | ADP OF THE SNF | since 01/13/2025 |
| YOSEF MEYSTEL DELTA TRUST | Organization | ADP OF THE SNF | since 07/01/2024 |
| HELLMAN, YOSEF | Individual | ADP OF THE SNF | since 01/13/2025 |
| HOFFMAN, JOSHUA | Individual | ADP OF THE SNF | since 01/13/2025 |
| SEITLER, DOVID | Individual | ADP OF THE SNF | since 01/13/2025 |
CMS files one row per role, so the 20 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $959K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145985. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-02-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.