Flanagan Rehabilitation and Health Care Center
201 East Falcon Highway, Flanagan, IL 61740 · For profit - Corporation · 43 certified beds · (815) 796-2267 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0567, F0568, F0569)
- it has 8 actual-harm citations
- a high number of inspection citations overall (52) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $31,327 in federal fines (most recent 2024-01-24)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 27.2% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.9% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 36.6% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 21.6% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.8% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.3% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.2% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 2.2% | 1.4% | worse |
| Short-stay residents rehospitalized after admission | 18.2% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.8% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.39 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.15 | 2.22 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.2% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 39% 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 | 43.2%CMS range 31.3–61.8 | 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 | 9.9%CMS range 6.4–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| 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 43 beds and averages 36.9 residents a day — about 86% occupied, or roughly 6 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 2.94 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 2.62 hrs/resident/day on weekends vs 3.07 on weekdays — 15% thinner on weekends. RN hours go from 1.14 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 21% is below 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
52 citations, most serious first. The 18 most serious are shown; the remaining 34 are one tap away and print in full.
- Actual harm · G2025-09-18 · 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 ensure a controlled medication was not stopped abruptly without notifying the physician for one of two residents (R1) reviewed for medication errors in the sample list of three. This failure resulted in R1 becoming unresponsive, falling, and being transferred to the hospital with benzodiazepine withdrawal, delirium, and syncope after R1's Ativan (benzodiazepine) was stopped abruptly.Findings include:R1's Minimum Data Set, dated [DATE] documents R1 has moderate cognitive impairment. R1's active Care Plan dated 7/18/25 documents the following: R1 has anxiety and intellectual developments. Interventions include give medication as ordered and monitor/document side effects and effectiveness, and to monitor for signs/symptoms of behaviors. The Care Plan documents R1 has diagnoses of Developmental Intellectual Disability, Depression and Anxiety Disorder. R1's July, August and September Medication Administration Record (MAR) documents a physician order from the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-07-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to address resident's care needs to obtain appointments in a timely manner, resulting in a delay in the removal of a gastrostomy feeding tube and a delay in podiatry services for an infection for (R15). R15 is one of three residents reviewed for infections/ medical devices in the sample list of 27.These delays resulted in R15's transfer to the local hospital, for antibiotic treatment of G-tube infection, and ingrown toenail infection.Findings include:1. R15's current diagnoses list documents the following: Gastrostomy Status (abdominal, surgical G-Tube feeding catheter), Unspecified Severe Protein Calorie Malnutrition.R15's Physician Order Note dated 5/16/25 documents V19, Medical Director/Physician gave the facility a verbal order as follows: Ok for resident to have her enteral (abdominal surgically inserted, Gastrostomy feeding tube) tube removed.R15's Minimum Data Set, dated [DATE] documents R15's Brief Interview of Mental Status score as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · G2024-01-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to treat residents with respect, dignity and provide care in a manner that promotes quality of life by not allowing a resident to have a say in medical treatment for one of four residents (R3) reviewed for respiratory care in the sample of six. This failure resulted in R3 being fearful of staff and experiencing ongoing psychosocial harm of R3; which resulted in R3 being sent to the emergency room for an anxiety attack. Findings Include: R3's MDS (Minimum Data Set) dated 12/24/24 documents R3 is alert and oriented. R3's January 2023 Physician Orders document the following orders: oxygen at 2-5 L (liters) per NC (Nasal Cannula) or vented mask, and BiPAP (BiLevel Positive Airway Pressure) with 6 LPM (liters per minute) oxygen bled into it. R3's ongoing diagnoses list includes the following diagnoses: COPD (Chronic Obstructive Pulmonary Disease), Chronic Respiratory Failure with Hypoxia, Dependence on Respirator or Ventilator, Dyspnea, On 1/22/24 at 7:30 pm, R3 was lying awake in bed with oxygen running at 4.5 L/NC. R3 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-01-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to notify the physician of a pressure ulcer to obtain an appropriate wound treatment, assess and document the pressure ulcer, notify the resident representative of a pressure ulcer and prevent cross contamination of the wound during a treatment for one of three residents (R2) reviewed for wounds in the sample list of six. This failure resulted in R2's MASD (Moisture Associated Skin Damage) progressing to an unstageable pressure ulcer. Findings Include: R2's ongoing diagnoses listing documents R2 has TBI (Traumatic Brain Injury), Morbid Obesity, and Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting Right Dominant Side. On 1/22/23 at 11:22 am, V10 (R2's POA (Power of Attorney) stated R2 was at the hospital on 1/21/23 and the nurse there said R2 has an open area on R2's buttocks. V10 also stated the nurse reported R2 also has another big area that is ready to break open. V10 stated V10 had never been notified by the facility that R2 had any wounds. R2's Hospital Notes dated 1/22/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2024-01-24 · 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
Based on observation, interview and record review, the facility failed to follow physician orders for respiratory care including oxygen, BiPAP and C-PAP usage, change oxygen tubing and humidifier bottles as ordered and document resident complaisance/non-compliance of respiratory care for four of four residents (R1, R2, R3, R4) reviewed for respiratory care in the sample list of six. This failure resulted in psychosocial harm of R3. R3 was sent to the hospital after having a panic attack and remains fearful of facility staff's action related to R3's respiratory care. Findings Include: 1. R3's January 2023 Physician Orders document the following orders: oxygen at 2-5 L (liters) per NC (Nasal Cannula) or vented mask, change oxygen tubing and humidifier once a week (scheduled for Sundays), and BiPAP (BiLevel Positive Airway Pressure) with 6 LPM (liters per minute) oxygen bled into it. R3's ongoing diagnoses list includes the following diagnoses: COPD (Chronic Obstructive Pulmonary Disease), Chronic Respiratory Failure with Hypoxia, Dependence on Respirator or Ventilator, and Dyspnea.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2023-09-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to protect the residents right to be free from mental and verbal abuse by a staff member for one of five residents (R10) reviewed for abuse in the sample list of 11. This failure resulted in psychosocial harm for R10 as evidenced by R10 being tearful and shaking while talking about the abuse three days later and R10 being fearful of retaliation from the staff member for reporting the abuse. Findings Include: The facility's Abuse Prevention Program dated 11/28/16 documents this facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility is committed to protecting our residents from abuse by anyone including; but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse is defined as the willful injection of injury, unreasonable confinement, intimidation,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-07-19 · tag 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 A. Based on observation, interview and record review, the facility failed to assess a surgical wound weekly, complete dressing changes as ordered to prevent a surgical wound from deteriorating, failed to notify the physician/wound practitioner of the wound decline and failed to implement nutritional interventions for wound healing for one of one residents (R32) reviewed for surgical wounds on the sample list of 17. This failure resulted in delayed wound healing and R32's surgical wound increasing in size. B. Based on observation, interview and record review, the facility failed to apply a splint/brace as ordered for one of two residents (R19) reviewed for splints/braces on the sample list of 17. Findings Include: A.) On 7/16/23 at 8:45 AM, R32 stated R32 has a foot wound on R32's right foot caused by a screw that R32 stepped on at R32's house. R32 explained R32 had surgery for it, but the doctor went too deep and caused more issues. R32 stated it was making great progress healing then stopped. R32's Dietitian…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2023-07-19 · tag 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 prevent the development of a deep tissue injury pressure wound, failed to notify the physician and/or wound practitioner of a newly developed deep tissue injury and obtain treatment orders and document the deep tissue injury for one of two residents (R32) reviewed for pressure injuries on the sample list of 17. This failure resulted in R32 developing a new deep tissue injury to the plantar surface of the right foot. Findings Include: The facility Decubitus Care/Pressure Areas Policy dated January 2018 documents it is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcers. Upon notification of skin breakdown, the QA (Quality Assurance) form for Newly Acquired Skin Conditions will be completed and forwarded to the Director of Nursing. The pressure areas will be assessed and documented on the Treatment Administration Record or the 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 before2025-09-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure care plans included problems, goals, and interventions to address diagnoses and medication use for two of three residents (R2, R3) reviewed for medications in the sample list of three. Findings include:1.) R2's active diagnoses list includes epileptic seizures related to external causes, not intractable, without status epilepticus. R2's September 2025 Medication Administration Record (MAR) documents R2 receives Lamotrigine 200 milligrams (mg) by mouth twice daily for seizures since 2/3/24 and Phenytoin Sodium100 mg give two capsules by mouth twice daily for seizures since 5/24/25.R2's active care plan does not include a problem, goal, and interventions for R2's seizure disorder and seizure medications. On 9/18/25 at 12:55 PM V2 Director of Nursing confirmed R2's seizure disorder and seizure medications were not on R2's care plan. V2 stated V2 is responsible for updating the care plans and V2 will update R2's care plan. 2.) R3's September 2025 MAR documents R3 receives Tramadol (opioid) 50 mg one tablet by mouth daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-18 · 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 implement a bowel program for one of three residents (R3) reviewed for medications in the sample list of three. Findings include:R3's August and September 2025 Medication Administration Records document R3 receives Tramadol (opioid) 50 milligrams by mouth daily since 4/18/23 and Milk of Magnesia 30 milliliters daily as needed for constipation. These records document R3 does not receive any scheduled bowel medications and did not receive any doses of Milk of Magnesia. R3's Minimum Data Set, dated [DATE] documents R3 has severe cognitive impairment and requires dependence on staff for toileting hygiene. R3's active care plan does not address R3's Tramadol use and monitoring, including risk for constipation. R3's Bowel Tracking Report with date range 8/20/25-9/18/25 documents the following: Large on 8/20/25. None 8/21/25-8/23/25. Large on 8/24/25. None 8/25/25-8/27/25. Large on 8/28/25. None 8/29/25-9/1/25. Large on 9/2/25. None on 9/3/25 and 9/4/25. Large…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · E2025-07-29 · tag F0580 — failed to tell family and doctor about changes — patternImmediately 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 observation, interview and record review the facility failed to notify the physician in a timely manner of a delay in the removal of a gastrostomy feeding tube for (R15), a delay in podiatry services for infection for (R15) and a delay in the removal of an Internal Jugular (IJ), Peripherally Inserted Central Catheter (PICC) post the administration of antibiotics for (R30). R15 and R30 are two of three residents reviewed for infection/antibiotics/ surgically implanted devices in the sample list of 27. Findings include:1. 1. R15's current diagnoses list documents the following: Gastrostomy Status (abdominal, surgical G-Tube feeding catheter), Unspecified Severe Protein Calorie Malnutrition .R15's Physician Order Note dated 5/16/25 documents V19, Medical Director/Physician gave the facility a verbal order as follows: Ok for resident to have her enteral tube removed.R15's Minimum Data Set, dated [DATE] documents R15's Brief Interview of Mental Status score as 13 out of a possible 15, indicating no cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · D2025-07-01 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 Social Services Director failed to conduct follow up visits following an abuse allegation for one resident (R3) of five residents reviewed for abuse from a sample list of five residents.Findings include:The facility's Abuse policy dated 3/25 documents that Social Service will follow up with any residents after an allegation is made and document the visit in the chart of the resident.R3''s Nursing Note dated 6/4/2025 at 4:45PM documents the Interdisciplinary Team (IDT) met to follow up on R3's recent allegation against a staff member. The investigation was completed, and the allegation was unfounded. R3's reportable dated 5/22/25 stated social service will meet with R3 twice a week for the next four weeks.R3's Quarterly Minimum Data Set, dated [DATE] documents R3 is cognitively intact and R3 reported V7 and V11 Certified Nursing Assistants (CNA's) to the facility. It was noted R3 has a history of Post Traumatic Syndrome Disorder (PTSD) and V4 did not speak with R3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · E2024-07-03 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to safeguard and account for resident monies held in the resident trust fund cash box. This failure affects 19 residents (R2, R3, R5, R6, R8, R9, R10, R12, R13, R14, R16, R17, R19, R20, R21, R22, R23, R24, and R25) out of 25 reviewed for resident funds on the sample list of 25. Findings include: On 7/2/24 at 9:45 AM, V1, Administrator, stated, (V3) was the Business Office Manager but no longer works here because (V3) wasn't handling the resident trust fund cash according to facility policy. V1 further stated, (V3) was the person who discovered the discrepancy with the funds. The facility's Investigative Final Report dated 6/24/24 documents, On 6/16/24 the BOM (Business Office Manager, V3) noted the trust fund cash on hand was not correct and found the missing amount to be $489.82. The facility's Individual Resident Fund Ledgers document R2, R3, R5, R6, R8, R9, R10, R12, R13, R14, R16, R17, R19, R20, R21, R22, R23, R24, and R25 all have resident trust fund accounts held and managed by the facility. The facility's Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-03 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
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 convey resident funds to a resident's estate or probate within the required 30 days after death. This failure affects one resident (R7) out of 25 reviewed for resident funds on a sample list of 25. Findings include: R7's Electronic Medical Record Resident Listing (undated), Minimum Data Set ([DATE]), and Nurses Notes ([DATE]) all document R7 expired on [DATE]. R7's Individual Resident Trust Fund Ledger provided by V1, Administrator, on [DATE] documents R7 maintained a current balance of $125.00 as of [DATE]. The Facility Resident Trust Fund Policy dated 9/2012 documents, Resident personal funds must be refunded within 30 days of discharge. In the case of resident death, the facility shall convey the residents personal fund balance and any unused room and board with a final accounting of the balance to the resident's estate or the person administering the estate. Release of such funds will require a proof of claim to the funds. If the facility receives…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This failure affects three of seven residents (R1, R2, R5) reviewed for abuse in the sample of seven. Findings Include: The facility's Abuse Prevention and Prohibition Policy dated January 2024 documents the facility affirms the right of its residents to be free from abuse and free from mistreatment by anyone. Resident behaviors will be monitored for changes, which could trigger abusive behaviors. Resident to Resident abuse includes the term willful. The word willful means that the individual's action was deliberate regardless of whether the individual intended to inflict injury or harm. Physical abuse can include such things as hitting, slapping, punching, and kicking. The Abuse Investigation Summary dated 5/9/24 documents on 5/4/24 staff were wheeling R5 to the dining room and wheeled past R1. Unprovoked, R1 reached out and began punching R5 in the arm. R1 and R5 were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2024-05-08 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview the facility failed to ensure the facility's Medical Director and Director of Nursing attended Quality Assurance meetings. This failure has the potential to affect all 27 residents residing in the facility. FINDINGS INCLUDE: The faciliy's Application for Medicaid and Medicare dated 5/6/24 documents there are 27 residents residing in the facility. The facility's Quality Assurance policy dated 2022, documents, The QAPI (Quality Assurance Preformance Improvment) consists of monthly and quarterly meetings, daily quality assurance activities, QAPI Tasks and Performance Improvement Plans. QAPI sign-in sheets dated 10/26/23 did not include signatures from the Director of Nursing (DON) or Medical Director/ Physician. On 05/06/24 at 01:08 PM, V1 Administrator in Training states that on 10/26/23, the facility did not have a DON at that time and the Medical Director was not in attendance for the QA meeting. V1 stated she was unable to show that facility reviewed the QA meeting with the Medical Director.
- Potential for harm · Ecited before2024-05-08 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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 identify resident specific targeted behaviors and implement nonpharmacological interventions prior to the use and increase of psychotropic medications for two (R1, R19) of five residents reviewed for psychotropic medications on the sample list of 23 residents. Findings Include: 1. R1's electronic health record documents current orders for Geodon (Antipsychotic) Hydrochloride 60 milligrams (mg)by mouth twice a day and Sertraline (antidepressant) Hydrochloride 100 MG (Sertraline HCl) by mouth one time a day. R1's medical record does not contain resident specific targeted behavior or resident specific interventions or response to interventions. Though the facility did utilize a preprinted behavior tracking. the behaviors/interventions listed were not specific to R1. On 4/8/24 at 12:00 PM, V2 Director of Nursing verified the facility uses the same computer-generated list of behaviors and interventions for all residents who require behavior tracking. 2. R19's undated Facesheet documents R19 has a diagnosis of unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2024-05-08 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions and failed to perform hand hygiene during incontinence care for four (R8, R9, R1 and R24) of 16 residents reviewed for infection control on the sample list of 23. Findings include: The facility's Infection Prevention and Control Manual-Enhanced Barrier Precaution policy dated 12/30/22 documents Enhanced Barrier Precautions are recommended for residents with wounds or an indwelling medical device including urinary catheters. This policy documents a gown and gloves should be worn when providing wound care and caring for or using an indwelling medical device. 1. On 5/06/24 at 10:11 AM, R8 was sitting up in a chair. An indwelling catheter was present. R8 stated he is provided with catheter care every day. R8 stated they wear gloves, but they do not wear a gown. On 5/7/24 at 11:00 AM, V9 Certified Nurse's Assistant (CNA) and V10 CNA entered R8's room to perform catheter care. There was not a sign outside of the door to indicate that R8 required enhanced barrier precautions. V9…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 34 citations
- Potential for harm · D2024-05-08 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one of 12 residents (R13) reviewed for call lights on the sample list of 23. Findings Include: On 5/06/24 at 1:20 PM, R13 was sitting up in the reclining chair in R13's room in front of the television. R13's call light was stretched all the way to the middle of the room and tied to a water jug on the over bed table, which is next to the back of R13's chair. The water jug was on the far end of the table, out of R13's reach. R13 attempted to reach the call light and was not able to. On 5/06/24 at 1:26 PM, V10 CNA (Certified Nursing Assistant) entered R13's room and confirmed that R13 was not able to reach the call light and stated, I wonder why (R13) is like that. R13 care plan dated 3/18/24 documents R13 has impaired physical mobility. This care plan includes an intervention to keep the call light within reach.
- Potential for harm · D2024-05-08 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide quarterly statements for one (R9) of sixteen residents reviewed for resident funds on the sample list of 23. Finding include: R9's Quarterly Minimum Data Set assessment dated [DATE] documents R9 is cognitively intact. On 5/06/24 at 9:36 AM, R9 stated the facility manages her money. R9 stated R9 does not get quarterly statements. R9 stated she would be interested in seeing them. On 5/6/24 at 1:15 PM, V4 Business Office Manager stated V4 has not provided quarterly statements to the residents since the company had a data breach in October of 2023. V4 stated this has been since the third quarter of last year and the first and second quarter of this year.
- Potential for harm · Dcited before2024-05-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and record review, the facility failed to document care plans including resident centered interventions for respiratory care for one of 24 (R29) residents reviewed for care plans in a sample list of 24 residents. R29's MDS (Minimum Data Set) dated 4/2/24 documents R29 is alert and oriented. R29's ongoing Diagnosis Listing documents a diagnosis of Chronic Respiratory Failure with Hypoxia. R29's May 2024 Physician Orders document to use oxygen at 2-4 L (liters) per nasal cannula to keep oxygen saturation levels above 92 % and Albuterol {Bronchodilator} nebulizer every four hours as needed for shortness of breath and wheezing. R29's Care Plan dated 4/9/24 does not document any respiratory problems or needs. On 5/06/24 at 9:19 AM, R29 was sitting up in the wheelchair and was not wearing oxygen. At this time, R29 stated R29 wears oxygen all the time when in bed and uses the nebulizer on average once a day for shortness of breath.
- Potential for harm · D2024-05-08 · 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 record review and interview the facility failed to update the physician on significant weight changes for one of one resident (R29) reviewed for weight changes on the sample list of 23. Findings Include: R29's MDS (Minimum Data Set) assessment dated [DATE] documents R29 is alert and oriented. On 5/06/24 at 9:37 AM, R29 stated R29 has not had any weight changes that R29 is aware of. R29's ongoing weight log documents the following weights: 1/3/24 - 126.6 pounds 2/6/24 - 129.6 pounds 3/3/24 - 141.6 pounds (a weight gain of 9.26% in one month) 4/4/24 - 136.4 pounds(a weight loss of 3.67% in one month) 5/7/24 - 156.8 pounds (a weight gain of 14.96% in one month) On 5/8/24 at 9:57 AM, V2 Director of Nursing stated the facility would re-weigh residents to make sure there was no issues and ensure that they had calculated the weight correctly, along with notifying the physician and assessing the resident to see if there is a reason for the weight gain such as edema. R29's Progress Notes do not document any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-08 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to administer medications in accordance with physician orders and manufacturer's instructions for three (R8, R2, and R11) residents reviewed for medication administration in the sample list of 23. The facility had four medication errors out of 28 opportunities resulting in a 14.28% medication error rate. Findings include: 1.) On 5/7/24 at 11:00 AM, R8 was noted to be sitting in his room after breakfast. At 11:33 AM, V6 Registered Nurse administered two units of fast acting insulin (Lispro) to R8. At that time, R8 stated he had already eaten breakfast. The Lispro Package insert documents to, Administer the dose of Insulin Lispro within fifteen minutes before a meal or immediately after a meal by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. 2.) On 5/7/24 at 11:50 AM, V19 Registered Nurse administered one tablet of Lactaid to R2 without food. The 12/21/23 package insert for Lactaid documents to take the tablet with the first bite of dairy food. 3.) On 5/7/24 at 3:07…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-18 · tag F0626 — isolatedPermit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
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 allow a hospitalized resident to return to the facility. This failure affects one resident (R1) out of 5 reviewed for transfers and discharges in the sample of 5. Findings include: On 3/16/24 and 3/18/24, R1 was not residing in the facility and R1's designated room was not occupied by R1 nor any other resident. R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Diffuse Traumatic Brain Injury with Loss of Consciousness of Unspecified Duration, Functional Quadriplegia, Acute and Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes with Hyperglycemia, Morbid (Severe) Obesity Due to Excess Calories, Epilepsy, Body mass Index [BMI] 45.0 - 49.0 Adult, Cerebral Infarction due to Thrombosis of Cerebral Artery, Depression, Nonpsychotic Mental Disorder, Pseudobulbar Affect, Dysphagia Oropharyngeal Phase, Hyperlipidemia, GERD, Hemiplegia and Hemiparesis, HTN, Dependence on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-24 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have 24 hour a day nurse coverage and failed to have enough nurse staffing to ensure medications were administered as ordered. This failure has the potential to affect all 30 residents who reside at the facility. Findings Include: R5's MDS (Minimum Data Set) dated 1/12/24 documents R5 is alert and oriented. On 1/22/24 at 9:36 am, R5 stated sometimes our night medications are late. Last Thursday night (1/18/24), I (R5) don't know what happened but they {staff} said the nurse wasn't available and then last night, the same nurse had to send someone to the hospital so my 8:00 pm medications weren't given to me until about 12:00 am. R3's MDS dated [DATE] documents R3 is alert and oriented. On 1/22/24 at 7:30 pm, R3 stated on 1/21/24, V6 did not give R3, R3's 8:00 pm medications until around 11:00 pm. R3 also stated V6 had turned R3's oxygen up too high last week and would not listen to R3 about turning it down so V5 CNA (Certified Nursing Assistant) ended…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2024-01-24 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to have a nurse serving as Director of Nursing (DON.) This failure has the potential to affect all 30 residents residing at the facility. Findings Include: On 1/22/24 from 8:00 am - 4:30 pm and 7:00 pm - 11:00 pm, there was no nurse working as the DON (Director of Nursing). At 2:55 pm, V4 LPN (Licensed Practical Nurse) stated the facility does not have a DON and that V4 is the only facility nurse therefore there is no guidance being provided for nursing staff. On 1/23/24 from 9:00 am - 4:30 pm there was no nurse working as the DON. On 1/23/24 at 3:30 pm, V1 AIT (Administrator in Training) stated the facility has not had a DON since February 15, 2022. The Facility assessment dated [DATE] documents the facility will employee other nursing personnel; those with administrative duties for 8-16 hours a day. The facility Resident Room and Bed Roster Form dated 1/22/24 documents 30 residents reside at the facility.
- Potential for harm · F2024-01-24 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain the facility in a safe, structurally intact, environment. This failure has the potential to affect all 30 residents residing at the facility. Findings Include: On 1/22/24 at 8:40 am, the bottom of the hallway wall outside of the shower room was crumbled, approximately 6 inches up off the floor and 4 feet long. There were large chunks of a concrete looking substance lying on the floor, in the hallway, under a shower bed that was pushed up against the wall. At this time, V4 LPN (Licensed Practical Nurse) stated V4 started working at the facility in November 2023 and noticed the wall crumbling in December 2023. At this time, V26 CNA (Certified Nursing Assistant) stated V26 has worked at the facility for 3.5-4 years and that the wall has been like that a long time, 6-12 months. On 1/22/24 at 9:12 am, V1 AIT (Administrator in Training) stated the wall outside of the shower room has been an ongoing issue. It crumbles, (V8 Maintenance Director) fixes it, then it crumbles again. It probably needs fixed again.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident from potential further abuse during an abuse investigation for one of four residents (R3) reviewed for respiratory care in the sample list of six. Findings Include: R3's MDS dated [DATE] documents R3 is alert and oriented. On 1/22/24 at 7:30 pm, R3 stated V6 had turned R3's oxygen up too high last week and would not listen to R3 about turning it down so V5 CNA (Certified Nursing Assistant) ended up reporting it to V1 AIT (Administrator in Training). R3 stated R3 is still waiting to talk to V1 about it. On 1/22/24 at 8:05 pm, V5 CNA (Certified Nursing Assistant) stated on 1/18/24 around 9:15 pm there was a situation between V6 Agency RN (Registered Nurse) and R3 that occurred with V5 and V17 CNA present which resulted in V5 and V17 both reporting an allegation of verbal/mental abuse to V1 AIT (Administrator in Training). V5 stated actually the allegation was reported to V1 by four different staff members, all whom had witnessed a part…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to complete wound assessments, complete wound treatments as ordered, perform hand hygiene to prevent cross contamination of the wound, and notify the physician of not having treatment supplies for two of three residents (R5, R6) reviewed for wounds in the sample list of six. Findings Include: The facility's Skin Condition Monitoring Policy dated January 2002 documents upon notification of a skin lesion, wound, stasis ulcer, or other skin abnormality, the charge nurse will assess and document the findings. Any skin abnormality will have a specific treatment order for frequency. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: characteristic: size, shape, depth, color and presence of granulation tissue or necrotic tissue, the treatment and response to treatment, and prevention techniques. The facility's Hand Hygiene…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-24 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain a complete and accurate medical record for one of four residents (R3) reviewed for respiratory care in the sample list of six. Findings Include: On 1/22/24 at 7:30 pm, R3 stated over the weekend, R3 was short of breath and had called for the nurse, V6 Agency RN (Registered Nurse) to give R3 a breathing treatment. R3 stated when V6 entered R3's room, V6 cranked R3's oxygen level up to 10 L/NC. R3 stated this has actually happened twice now. On 1/22/24 at 8:05 pm, V5 CNA confirmed R3 had an episode on 1/18/24 and again on 1/20/24 where R3 was in respiratory distress; very short of breath and requesting a PRN (as needed) nebulizer treatment. V5 stated that V6 Agency RN (Registered Nurse) ended up turning R3's oxygen up to 10 L (liters) per nasal cannula, and giving R3 an inhaler along with the nebulizer. V5 stated R3 was sent out to the hospital on 1/20/24 because of this but returned later in the night. R3's Progress Notes from 1/17/24 - 1/23/24 does not document any episodes of respiratory distress or actions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2023-10-24 · 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 — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to employ a Director of Nursing. This failure has the potential to affect all 32 residents in the facility. Findings Include: On 10/24/23 at 10:45am, V1 Administrator in Training (AIT) confirmed the facility does not have a DON. V1 stated V1 has scheduled multiple DON interviews but the person cancels or does not show up. V1 stated the facility has not had a DON for almost two years. On 10/24/23 at 10:49am, V4 Certified Nursing Assistant stated the facility does not have a DON. The facility Resident Room and Bed Roster dated 10/24/23 documents 32 residents reside at the facility.
- Potential for harm · Fcited before2023-09-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services of a Registered Nurse for at least eight consecutive hours a day, seven days a week and failed to have a Director of Nursing. This failure has the potential to affect all 36 residents who reside at the facility. Findings Include: On 9/2/23 at 8:20 am, R1 stated the facility has not had a DON (Director of Nursing) since R1 was admitted to the facility, therefore if R1 has a problem with cares, there isn't anyone to take R1's concerns to and nobody to hold the staff accountable, it's a free for all. On 9/2/23 from 8:20 am - 1:00 pm, there was no DON in the facility or an RN (Registered Nurse) working the floor. On 9/2/23 at 1:10 pm, V1 AIT (Administrator in Training) stated the facility does not have a DON and hasn't since February 2022, 19 months ago. V2 also stated, the facility use to have an RN that would be at the facility on the weekend however V6 RN, quit without notice on 8/31/23. The August and September 2023 Nurses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2023-09-03 · 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, interview and record review, the facility failed to maintain a comfortable sound level for three of four residents (R6, R7, and R9) reviewed for homelike environment in the sample list of 11. Findings Include: On 9/2/23 at 9:25 am, V12 (R7's family) stated that R6, R7's roommate plays the music too loud giving R6 a headache. V12 explained R7 likes music but when R7 is trying to rest and the music is loud, R7 can't. The facility staff have told R6 to turn it down which R6 will do but as soon as the staff leave the room, R6 turns it back up. V12 stated, V12 knows it's R6's right to listen to the music but what about R7's rights? Nothing is being done about it. R6's Progress Notes dated 7/18/23 document V4 SSD (Social Service Director) discussed R6's stereo with V11 (R6's family). The stereo volume control does not work, and it only plays loud. V11 will look into a different system and the facility staff will also see if there is anything available here, at the facility. R7's Progress Notes document the following: 7/27/23 - CNA (Certified Nursing Assistant) staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as Director of Nurses and failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/16/23, 7/17/23, 7/18/23, and 7/19/23 there was no Director of Nurses present in the facility. On 7/18/23 at 3:50 PM V1 Administrator confirmed the facility did not have eight hours of Registered Nurse coverage every day, 7 days a week during the time frame reviewed. V1 also confirmed the facility's average daily census was around its current census of 36 residents. V1 also confirmed the facility has not employed a Registered Nurse to serve as Director of Nurses since February of 2022. Facility Nursing Staff Monthly Assignment Calendar reviewed from 2/1/23 through 7/19/23 documents 44 days that the facility failed to use the services of a Registered Nurse for at least…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-19 · tag F0837 — widespreadEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have a governing body in which the facility failed to have a licensed Administrator managing the facility. This failure has the potential to affect all 36 residents residing in the facility. Findings Include: Upon survey entrance and throughout the survey (7/16/23-7/19/23) there was no licensed administrator managing the facility. On 7/17/23 at 2:10 PM V1 AIT (Administrator in Training) stated V1 applied for her temporary Administrator's license two weeks ago but has not received it yet. V1 stated that the previous administrator left the building in January of 2023, and it was at that time that V1 took over the role of AIT. V1 stated she is able to reach out to corporate if she needs help, but a licensed administrator is not regularly in the building to train or provide guidance concerning ongoing issues within the facility. The facility's Facility assessment dated [DATE] documents the facility will be staffed according to resident's needs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-19 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop a thorough and complete Quality Assurance and Performance Improvement (QAPI) Program, failed to sustain the QAPI program during transitions in leadership, and failed to implement the QAPI Program by failing to identify and prioritize problems and make good faith attempts to address those problems. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/17/23 at 2:10 PM V1 Administrator in Training (AIT) confirmed the facility has not been implementing a complete QAPI program and V1 stated she is not sure exactly sure what all the QAPI program entails. V1 stated she took over the building as AIT in January 2023 and the facility has not held a Quality Assurance and Performance Improvement meeting since she took over. V1 also confirmed the facility does not have a QAPI program that she could find, the only QAPI information she could provide was a QAPI committee agenda form. The undated Quality Assurance Plan documents the facility's Quality Assurance Committee will conduct…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-07-19 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop a thorough and complete Quality Assessment and Assurance (QAA) of Policies and Procedures and a Quality Assurance and Performance Improvement (QAPI) Program and failed to implement the QAA and QAPI Programs by failing to identifying quality deficiencies, develop and implement appropriate plans of action to correct such deficiencies, regularly review and analyze data, act on available data to make improvements, conduct distinct Performance Improvement Projects (PIPs), and implement corrective actions and mechanisms that include feedback and learning throughout the facility. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/17/23 at 2:10 PM V1 Administrator in Training confirmed the facility only held two QAA meetings over the last year and had not held a QAA meeting at all in the year 2023. V1 stated they have not had a QAA meeting since November 2022. V1 also confirmed that since they have not had a Director of Nurses or an Infection Preventionist those positions 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 · Fcited before2023-07-19 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure the required quarterly Quality Assessment and Assurance (QAA) committee meetings were completed and failed to ensure the Director of Nurses and Infection Preventionist were members of the QAA Team and attended QAA meetings. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/17/23 at 11:00 AM V1 Administrator in Training provided two QAA Meeting Sign-in Sheets for the previous year's QAA meetings. One was dated 9/21/22 and the other was dated 11/30/22. On 7/17/23 at 2:10 PM V1 Administrator in Training confirmed the facility only held two QAA meetings over the last year and had not held a QAA meeting at all in the year 2023. V1 stated they have not had a QAA meeting since November 2022. V1 also confirmed that since they have not had a Director of Nurses or an Infection Preventionist those positions have not been involved in the QAA process or attended any meetings. The undated Quality Assurance Plan documents the facility's Quality Assurance Committee will conduct…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-19 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct infection control surveillance. This failure has the potential to affect all 36 residents in the facility. Findings Include: On 7/17/23 at 2:10 PM V1 Administrator in Training confirmed the facility has not kept an updated infection control surveillance log since March of 2023. The Infection Control Policy dated 3/8/23 documents the facility will keep an updated infection control log on a daily basis in order to analyze data and identify trends that would indicate need for additional controls to prevent any further spread of infection. The responsibility to maintain these records of surveillance and monitoring will be the Director of Nurses, Infection Preventionist, or Administrators. The Facility assessment dated [DATE] documents the facility shall track, trend, and monitor infections through the internal Quality Assurance Process, which is done daily, weekly, monthly, and quarterly. The Resident Census and Conditions of Residents report 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 · F2023-07-19 · 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 designate an onsite qualified Infection Preventionist who works at least part time in the facility. This failure has the potential to effect all 36 residents in the facility. Findings Include: Upon survey entrance and throughout the survey (7/16/23-7/19/23) there was no Infection Preventionist in the facility. On 7/17/23 at 2:10 PM V1 Administrator in Training confirmed the facility has not had an onsite Infection Preventionist in the building since October 2022. V1 stated V24 Regional Nurse has been filling in but has not been in the building for a couple weeks and is now off with an injury. V1 confirmed V24 has not been in the building enough to have the necessary time to properly manage the Infection Control Program, conduct training, and has not completed infection control requirements for or participated in the facility's Quality Assessment and Assurance (QAA) Committee meetings. The Infection Control Policy dated 3/8/23 documents the facility will employ, at a minimum, a part time Infection Control…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2023-07-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to initial and date oxygen and nebulizer tubing, and humidity bottles; and failed to keep respiratory items covered when not in use for five of five residents (R6, R8, R17, R22, R29) reviewed for respiratory care on the sample list of 17. Findings Include: 1. R8's undated Face Sheet documents R8's diagnoses as Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, COPD with acute exacerbation, Chronic Respiratory Failure with Hypoxia, Anxiety Disorder. R8's Physicians Order Sheet (POS) dated 7/18/23 documents an order for Oxygen at 3L (liters)/minute via nasal cannula every shift related to Chronic Respiratory Failure, keep sats (saturation) 88% - 92%; Oxygen tubing and humidifier change every Saturday night shift; Albuterol Sulfate 2.5 milligrams (mg)/3 milliliters (ml) solution give 3 ml by mouth every four hours as needed for cough/wheezing per nebulizer; Sodium Chloride 3% inhale vial give 4 ml by mouth every six hours as needed for wheezing/cough per nebulizer. R8's Care Plan dated 5/26/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-19 · tag 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, interview and record review, the facility failed to maintain a homelike environment for one of two residents (R17) reviewed for homelike environment on the sample list of 17. Findings Include: On 7/17/23 at 4:02 PM, R17 was lying in bed and a large hole was noted in the wall behind R17's bed, approximately 2 feet by 5 inches. V20 (R17's Family), who was at the bedside, stated the hole in the wall has been there for months. V20 reported that staff told V20 that the hole was caused from the bed hitting the wall when they reposition R17 in bed. On 7/18/23 at 9:16 AM, V6 Maintenance Supervisor stated V6 was aware of the hole in the wall but was not aware that it had gotten as big as it is and that you can literally knock on the wall of the other room through it. V6 stated things like this should be reported to V6 and placed in the Work Order Book. V6 checked the book and stated there is nothing documented, and the work orders go all the way back to August 2022. On 7/18/23 at 9:24 AM, V1 AIT (Administrator in Training) stated V1 was aware of the hole in the wall and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-19 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to provide a bed hold notice to two of two residents (R6, R16) reviewed for hospitalization on the sample list of 17. Findings Include: 1) R6's MDS (Minimum Data Set) dated 6/13/23 documents that R6 is alert and oriented. On 7/16/23 at 9:39 AM, R6 stated R6 was sent to the hospital last night (7/15/23) for chest pain and returned to the facility. R6 stated R6 was not given a bed hold notice at that time. R6's Progress Notes dated 7/15/23 does not document that a bed hold notice was provided to R6. On 7/16/23 at 3:27 PM, R6 was not in R6's room. At this time, V2 RN (Registered Nurse) stated that R6 was sent back to the hospital this afternoon for breathing issues. On 7/16/23 at 3:37 PM, V2 RN stated V2 did not give a bed hold notice to R6 today when V2 sent R6 out to the hospital. V2 explained V2 only works at the facility PRN (as needed) and was not aware of what the process is or if V2 was supposed to give one or not. 2) R16's Progress Notes dated 5/25/23 by V12 Agency LPN (Licensed Practical Nurse) documents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-19 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to complete the Minimum Data Set to accurately reflect the needs of two of two residents (R16, R19) reviewed for accurate MDS's on the sample list of 17. Findings Include: 1) On 7/17/23 at 8:35 AM, R16's bed had bilateral half siderails in the elevated position at the head of the bed. R16's Restraint-Enabler Evaluation dated 6/29/23 documents two upper half siderails are used for bed mobility and are not a restraint. R16's MDS (Minimum Data Set) dated 7/2/23 documents R16 uses siderail restraints daily. On 7/17/23 at 12:34 PM, V7 MDS/Care Plan Coordinator stated R16 does not use a restraint but does use half upper side rails to help R16 turn and reposition and steady R16's self when getting up out of bed and getting into bed. V7 explained V7 coded use of the siderails on the MDS under restraints even though they are not a restraint just because of R16 using them. 2) R19's July 2023 Physician Order Sheets document an order for a splint to the left hand with instructions for it to be worn as tolerated, including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to accurately reflect resident needs for two of 17 residents (R15, R16) reviewed for care plans on the sample list of 17. Findings Include: The facility Comprehensive Care Planning Policy revised 7/20/22 documents it is the policy of this facility to comprehensively assess and periodically reassess each resident admitted to this facility. It is to be noted that the care plan is for planning care and services. A comprehensive care plan shall be developed within seven days of the completion of the RAI (Resident Assessment Instrument). The care plan contains pertinent information about the resident including a summary listing of healthcare information such as physician orders, dietary orders, therapy services, and social services. The care plan is a plan of care describing a need/problem and indicating approaches/interventions to be instituted to assist the resident in maintaining/receiving care in relation to the need/problem. The comprehensive care plan shall strive to describe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-19 · tag 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 properly secure an oxygen cylinder and investigate a fall for two of two residents (R17, R4) reviewed for accident hazards on the sample list of 17. Findings Include: 1) On 7/16/23 at 9:47 AM, R17 was lying in bed with oxygen running at 2.5 liters per nasal cannula from an oxygen concentrator. There was a small portable oxygen cylinder sitting on the floor, without a stand or secured, behind the privacy curtain. On 7/18/23 at 12:03 PM, V7 MDS (Minimum Data Set)/Care Plan Coordinator stated portable oxygen cylinders should be stored in the oxygen room, and in racks. The oxygen cylinder in R17's room should have been secured in the back of R17's wheelchair, in the oxygen holder. The facility Oxygen Storage and Assembly Policy dated January 2002 documents oxygen tanks must be secured with a chain, on a cart or on a stand. 2) On 7/16/23 at 12:55 PM, V15 (R4's Family) stated V15 was notified a couple of weeks ago that R4 had a fall and R4 did have a sore on R4's leg last weekend when V15 was at the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-19 · tag 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete psychotropic medication assessments, identify residents targeted behaviors or implement non-pharmacological interventions for behavior management for two of five residents (R15, R4) reviewed for psychotropic medications on the sample list of 17. Findings Include: 1) R15's July 2023 Physician Orders document the following orders: Seroquel {Antipsychotic} 300 mg (milligrams) -one tablet every evening and Seroquel 200 mg - one tablet every day for Schizoaffective Disorder, Sertraline {Antidepressant} 25 mg - one tablet every evening for Major Depressive Disorder, and Lorazepam {Antianxiety} 1 mg - one tablet every evening for Anxiety Disorder. R15's Psychotropic Medication Review/assessment dated [DATE] documents R15 receives Seroquel for Schizoaffective Disorder and Intellectual Disabilities with indications for use of sadness and impulsive outbursts. There are no resident specific targeted behaviors identified and no assessment for the use 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 before2023-07-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to administer medications according to Physician Orders and follow Manufacturer's Recommendations for medication administration for two of four residents (R4, R11) reviewed for medication administration on the sample list of 17. The facility had four errors out of 26 opportunities for a medication error rate of 15.38%. Findings Include: 1) R11's July 2023 Physician Orders document orders that include the following: Metformin {Anti-diabetic} 1,000 mg (milligrams) one tablet BID (twice a day) and NovoLog Flex Pen with instructions to inject 15 units subcutaneously BID for type II Diabetes Mellitus in addition to sliding scale dose and inject as per sliding scale: if blood glucose level is 180 - 200 give 4 units, if 201 - 250 give 5 units, 251 - 300 give 6 units, 301 - 350 give 7 units, 351 - 500 give 10 units. On 7/17/23 at 9:22 am, V12 Agency LPN (Licensed Practical Nurse) prepared and administered R11's medications which included Metformin {Anti-diabetic}1,000 mg (milligrams) one tablet, which contained a warning…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-07-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 maintain accurate and complete medical records for two (R16, R4) of two residents reviewed for complete medical records on the sample list of 17. Findings Include: 1) On 7/16/23 at 9:11 AM, R16 was propelling R16's self down the hallway in a wheelchair wearing a brace to the right lower extremity, which kept R16's leg fully extended. At this time, V2 RN (Registered Nurse) stated R16 has worn the brace for as long as V2 can remember. On 7/17/23 at 8:31 AM, R16 was propelling R16's self down hall in a wheelchair wearing a brace to the right lower extremity. R16's July 2023 Physician Order Sheets do not document an order for a brace. On 7/17/23 at 1:09 PM, V14 PTA (Physical Therapy Assistant) stated R16 is not currently on Physical Therapy's case load however, R16 wears a brace to the right lower extremity because R16 says R16's knee buckles. V14 stated when R16 was on their caseload, years ago, V14 sent R16 to see an Orthotist and R16 was placed in the brace. V14 stated R16 use to have an order for it at 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 · Fcited before2022-06-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to designate a Registered Nurse to serve as a full time Director of Nursing. This failure effects all 25 residents residing in the facility. Findings include: On 6/7/22 at 11:40 am, V1, Administrator, stated, We don't have a DON (Director of Nursing) right now. On 6/7/22 at 1:02 pm, V2, Registered Nurse, stated, I am an agency employee but it is my understanding there isn't a DON right now. On 6/7/22 at 2:33 pm, V4, Licensed Practical Nurse, stated, That is a true story, we do not have a DON right now. It can be difficult when we need a reference for guidance. On 6/7/22 at 2:34 pm, V3, Regional Corporate Nurse Consultant, stated, I am an RN (Registered Nurse). I am the Corporate RN and QA (Quality Assurance) Nurse. I am serving as Interim DON. I do not work here full time because I have to spread myself between 3 facilities so I am here maybe 2 days per week. Then we have (V12, Registered Nurse) who is here maybe 1 day per week. The facility's (undated)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-09 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to flush a Peripherally Inserted Central Catheter (PICC) according to the doctor's orders, for one resident (R14) of one resident reviewed for PICC line flushes on the sample list of 18. Findings include: R14's Minimum Data Set (MDS) dated [DATE], documents R14 is cognitively intact. R14's Physician Order Sheet (POS) dated 6/1/22 to 6/30/22, documents an order to flush PICC with 10 milliliters (ml) of 0.9% sodium chloride weekly (10 ml each lumen). R14's Medication Administration Record (MAR) dated 5/31/22, documents PICC flush to be completed on 5/30/22 and was not signed off as being completed. R14's MAR dated 6/1/22 to 6/30/22, documents flush PICC weekly, due on 6/6/22 and was not signed off as being completed. On 6/9/22 at 10:30 AM, R14 stated the facility has not been flushing R14's PICC line. On 6/9/22 at 11:53 AM, V3 Registered Nurse (RN) (regional nurse), stated if that (flush) was not documented as being done (flushed) then it was not done.
- Potential for harm · Dcited before2022-06-09 · 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
Based on observation, interview, and record review, the facility failed to maintain oxygen administration equipment in a sanitary manner, failed to date oxygen tubing according to facility policy, and failed to develop their policy to address sanitary storage of oxygen tubing when not in use. This failure effects one resident (R7) out of one reviewed for oxygen and respiratory care on the sample list of 18. Findings include: R7's Cumulative Diagnoses List documents R7 has medical diagnoses including Mental Retardation, Flaccid Right Side Extremities, and Non-Psychotic Mental Disorder Following Organic Brain Damage and Traumatic Brain Injury. R7's current Care Plan dated 4/13/22 documents R7 experiences altered thought processes, memory problems, and is dependent upon staff to accomplish all activities of daily living including bed mobility, hygiene, dressing, and grooming. On 6/7/22 at 11:53 am, R7's nasal cannula oxygen tubing was wrapped onto R7's bed rail. The nasal prongs of the cannula were in direct contact with the bed rail. The nasal cannula oxygen tubing was not dated as 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$31,327 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $31,327 — penalty dated 2024-01-24
- Medicare payment denial — starting 2025-10-24 for 4 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $505K paid to related parties — landlords or management companies under common ownership — equal to about 13% 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 145842. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-08, 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.