Bria Of Geneva
1101 East State Street, Geneva, IL 60134 · For profit - Limited Liability company · 107 certified beds · (630) 232-7544 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (62%) runs well above the national median (45%)
- 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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 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 | 8.5% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.1% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 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 | 99.0% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.2% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 8.6% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.6% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.7% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.8% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 36.9% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 72.9% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 22.4% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.1% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.49 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.77 | 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.
43.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 43 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | 43.6%CMS range 35.5–55.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 7.2–15.7 | 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 | 46.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 58.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 4.4–14.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.29 | 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 107 beds and averages 95.1 residents a day — about 89% occupied, or roughly 12 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 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.33 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 4.00 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.58 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · Gcited before2023-09-14 · 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 implement specific interventions to prevent pressure ulcers from developing to a resident assessed as high risk. This applies to one of three residents (R1) reviewed for pressure ulcers. The findings include: The EMR (Electronic Medical Record) showed that R1, an [AGE] year-old with diagnoses that include but not limited to diabetes mellitus type 2, dementia, hypertension, Alzheimer's disease, cerebral infarction, hyperlipidemia, hyperkalemia, lack of coordination, weakness, kidney failure, metabolic encephalopathy, obesity, psychotic, mood and anxiety disturbance, and cognitive communication deficit. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) dated 7/25/2023 showed that R1 was severely impaired, required extensive to total assistance with ADLs (Activities of Daily Living) such as transfer, bed mobility, hygiene and eating. The MDS also showed that R1 had functional impairment of range of motion on one side 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 · D2025-05-14 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to ensure a resident was not served a food item to which the resident had an allergy. This applies to 1 of 3 residents (R1) reviewed for food concerns in a sample of 9. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including allergy status to unspecified drugs, medications, and biological drugs, irritant contact dermatitis, and disorder of skin subcutaneous tissues, asthma, heart failure, chronic obstructive pulmonary disease, and cirrhosis of the liver. R1's MDS (Minimum Data Set) dated 04/21/2025 showed R1's cognition was severely impaired and required one to two maximum assistance for activities of daily living. R1's allergy status upon admission dated 04/02/2025 showed R1 was allergic to peach and lactose, and R1's face sheet also listed R1's allergy under other information. On 05/13/2025 at 9:00 AM and on 05/14/2023 at 8:20 AM, V10 (R1's family) said the facility served peach on her lunch tray, and she caught it and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a portable oxygen tank that was full for a resident. This applies to 1 of 3 residents (R1) reviewed for oxygen in a sample of 3. The findings include: On 9/27/24 at 10:15 AM, surveyor and V2 (DON-Director of Nursing) went to R1's room. R1 was sitting in her wheelchair. At the back of her wheelchair, R1 had a portable oxygen tank that was connected to her nasal cannula. The dial was turned to 3 liters but it read empty. V2 removed the nasal cannula as instructed by the surveyor and put the nasal prongs near her wrist. Then, she passed it to surveyor who did the same thing. Both V2 and surveyor confirmed no air was able to be felt. R1 was asked if she felt any air and she said No! Surveyor asked R1 if she had any problems breathing or if she was in any type of distress. She stated no she was not. R1's oxygen saturation rate was 91%. On 9/27/24 at 10:18 AM, V2 stated that the tank should have been full or changed out. V2 also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · D2024-08-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of abuse to the abuse coordinator and Illinois Department of Public Health per facility policy. This applies to 2 of 3 residents (R1, R2) reviewed for abuse in a sample of 3. The findings include: Face sheet, printed 8/22/24, shows R1 was admitted to the facility on [DATE] and his diagnoses included acute kidney failure, adjustment disorder, vascular dementia, congestive heart failure, history of falls, depression, transient ischemic attack, and weakness. MDS (Minimum Data Set), dated 7/25/24, shows R1's cognition was moderately compromised. Face sheet, printed 8/22/24, shows R2 was admitted to the facility on [DATE] and his diagnoses included dementia, unspecified psychosis, depression, anxiety, psychoactie substance abuse, and insomnia. MDS, dated [DATE], shows R2's cognition was severely impaired. On 8/21/24 at 11:40 PM, R1 stated R2 was very confused and continuously wandered. R1 stated R2 continuously entered R1's room because…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide secure wheelchair transportation in facility van/bus for a resident. This applies to 1 resident (R1) reviewed for safe facility van transportation in a sample of 9. The findings include: R1's Face sheet shows diagnoses of morbid sever obesity, abnormalities of gait and mobility, generalized muscle weakness, history of falling, lack of coordination, and peripheral vascular disease. R1's MDS (Minimum Data Set) dated 6/10/24 shows her cognition is intact and she uses a wheelchair. R1's MAR (Medication Administration Record) shows she took PRN (as needed) doses of Tylenol on 7/11/24 at 2224 and again on 7/20/24. On 7/23/24 at 1:50 PM, V7 (Activity Director) said when she was driving the van on 7/11/24, a car drove out in front of her and she braked hard and R1 fell out of her wheelchair. V7 said she parked the van and went back to assess R1, who was sitting on the floor in front of her wheelchair with her left leg extended against the wall of the bus and her right leg extended under the wheelchair of R6,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · D2024-07-26 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide resident wheelchairs in safe, operating condition. This applies to 2 residents (R1 and R5) reviewed for safe equipment in a sample of 9. The findings include: 1. R5's Face Sheet shows he was recently admitted to the facility on [DATE]. On 7/23/24 at 10:21 AM, R5 showed surveyor that the wheelchair brake on his left wheel was loose and when in locked position the left wheel could still move. R5 said the wheelchair he was using was provided by the facility. 2. On 7/23/24 at 10:48 AM, R1 demonstrated for surveyor locking her wheelchair on both wheels and she was still able to move forwards and backwards while brakes were in lock position. R1 showed surveyor that her right wheel brake handle was also loose. On 7/25/24 at 1:57 PM, V11 (Maintenance Director) said a wheelchair wash was done in either June or July in the facility parking lot when maintenance is provided to wheelchairs in need. V11 said he could not recall if R1 was there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-06-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure dietary staff wore beard guards during food handling and failed to ensure food was covered to prevent contamination. This applies to all residents residing in the facility reviewed for food sanitation. The findings include: The facility's resident census provided on 6/24/24 shows 95 residents residing in the facility. On 6/24/24 during initial tour of the kitchen a full tray of mandarin oranges each placed in a serving bowl were in the fridge uncovered. At 11:40 AM, the food cart was in the downstairs dining room. The tray of mandarin oranges were not covered with the food cart open. At 12:04 PM, during the noon meal on the first floor dining room, V14 (dietary staff) was at the steam table plating the noon meal. A patch of outgrown hair was on the middle of V14's chin without a beard guard on. V15 (Dietary Staff) was preparing jelly sandwiches. V15's facial hair beard was outgrown with medium stubble, he was not wearing a beard guard. V13 (Dietary Staff) was in the kitchen cutting watermelon. He had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-26 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide ongoing monitoring and assessments for the use of a resident's wheelchair seatbelt/physical device. This failure applies to 1 of 1 (R12) residents reviewed for physical restraints in the sample of 19. The findings include: On 6/26/24 at 10:37 AM, R12 was seated in a wheelchair by the front desk of the facility. A seatbelt, attached to R12's wheelchair, was clasped securely around R12's waist. When R12 was asked about the seatbelt, R12 stated, I have had it for awhile. On 6/26/24, R12's electronic medical records dated June 2023-June 2024 were reviewed. R12's current care plan showed R12 had a diagnosis of cerebral palsy with contractures to her bilateral lower extremities and right hand. The care plan showed R12 required staff assistance for all activities of daily living. The care plan showed R12 used a seatbelt while in her wheelchair but showed no documentation as to the medical need for the R12's seatbelt. R12's electronic medical records showed no facility restraint or seatbelt assessments for R12.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2024-06-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide ADL (Activities of Daily Living) assistance to residents that require staff assistance for toileting/incontinence care for 3 of 19 residents (R12, R64, R53) reviewed for ADLs in the sample of 19. The findings include: 1. R12's current care plan showed R12 was completely dependent on staff for incontinence care related to her diagnosis of cerebral palsy. R12 was incontinent of bowel and bladder. The care plan showed, Keep resident clean and dry after each incontinent episode. On 6/24/24 at 8:57 AM and 9:30 AM, R12 was observed sleeping in a wheelchair in the television (TV) area of the facility's memory care unit. On 6/24/24 at 9:40 AM, V4 and V5 Certified Nursing Assistants (CNA) propelled R12 into her room to provide cares. As V4 and V5 transferred R12 into bed, R12 began scratching at her incontinence brief and stated itchy. V5 CNA was asked when R12 was last provided with incontinence care, V5 stated, Around 6 AM, when I got her out of bed. V4 and V5 removed R12's incontinence brief soiled with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide the necessary treatments for a resident's rash and for residents with leg edema. These failures apply to 3 of 19 residents (R12, R15, R64) reviewed for necessary care and services in the sample of 19. The findings include: 1. R12's current care plan showed R12 was completely dependent on staff for incontinence care related to her diagnosis of cerebral palsy. R12 was incontinent of bowel and bladder. The care plan showed, Keep resident clean and dry after each incontinent episode. R12's Skin and Wound Note dated 6/20/24 showed R12 had a MASD (moisture associated skin damage) fungal rash to her buttocks. The note showed, The patient is at increased risk for developing skin breakdown and moisture associated skin damage due to fecal and urinary incontinence, obesity, inability to perform self-care. On 6/24/24 at 8:57 AM and 9:30 AM, R12 was observed sleeping in a wheelchair in the television (TV) area of the facility's memory care unit. On 6/24/24 at 9:40 AM, V4 and V5 Certified Nursing Assistants (CNA)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2024-06-26 · 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 implement pressure relieving interventions for a resident at risk for pressure injuries and recently diagnosed with a new sacral injury for 1 of 4 residents (R29) reviewed for pressure injuries in the sample of 19. The findings include: R29's current care plan showed R29 was at risk for skin complications related to her diagnoses of dementia and incontinence. R29's Braden Scale for Predicting Pressure Sore Risk dated 5/19/24 showed R29 was at high risk for developing pressure injuries. A Skin Condition assessment dated [DATE] showed R29 had developed new redness and skin discoloration to both of her buttocks. The note showed, Orders . Resident to be re-positioned every two hours. Low air (loss) mattress to be provided per DON (Director of Nursing). On 6/24/24 at 9:18 AM, R29 was in bed, lying on a standard, hospital-type mattress. On 6/24/24 at 9:22 AM, V5 Certified Nursing Assistant (CNA) provided incontinence care to R29. A 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.
Show the remaining 21 citations
- Potential for harm · Dcited before2024-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to supervise a dementia resident, with a history of wandering behaviors, in a manner to prevent the resident from eloping from the facility. The facility failed to ensure oxygen tanks were safely secured in place. These failures apply to 2 of 19 residents (R29, R16) reviewed for safety and supervision in the sample of 19. The findings include: 1. R29's admission record showed R29 was admitted to the facility on [DATE] with a diagnosis of dementia. R29's Elopement Evaluations dated 1/5/24 and 2/6/24 showed R29 was at a high risk for elopement due to R29's impaired cognition, physical ability to leave the building, wandering around the facility, and R29 exhibiting behaviors of actively trying to exit the facility. R29's Behavior Note dated 1/28/24 showed R29 tried twice to get into the elevator but was stopped by staff. R29's Behavior Note dated 2/4/24 showed R29 was agitated and wanted to go out of the facility, resident is continuously seeking…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2024-06-26 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were administered per standards of practice which applies to 1 of 19 residents (R28) reviewed for medication services in a sample of 19. The findings include: R28's Facesheet printed on 6/26/24 showed R28 is an [AGE] year old male admitted to the facility with diagnoses which include: essential hypertension and heart failure. R28's Order Summary printed on 6/26/24 showed R28 has an order for Metoprolol Succinate ER 25 milligram (mg) tablet related to essential hypertension. On 6/24/24 at 10:25 AM, R28 was lying in bed watching television. R28 had a white oval pill on his chest. The pill had 564 stamped into the pill. The pill was dry and intact. R28 stated the nurse was in about 9 AM with his medications. On 6/24/24 at 10:35 AM, V17 Licensed Practical Nurse (LPN) identified the pill as R28's Metoprolol ER 25 mg dose. V17 stated she thought he took them all. V17 stated R28's medications were given to him about 9 AM. 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 · D2024-06-26 · 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 — the official record, unedited, may be distressing
Based on interview and record review the facility failed to provide R22 with informed consent for psychotropic medication for 1 of 5 residents (R22) reviewed for unnecessary medication in the sample of 19. The finding include: R22's Physicians Orders on 06/25/2024 shows, sertraline hydrochloride Oral Tablet 25 milligrams. Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, unspecified. On 06/26/24 at 12:42 PM, V3 ADON-Assistant Director of Nursing said, R22 was started on sertraline hydrochloride in January (2024). There was no consent. R22's Psychiatry Note dated 01/26/2024 shows, R22 has multiple diagnosis including amnesia. Unspecified dementia, unspecified severity, without behaviors/psychosis/mood/anxiety. Major Depressive disorder, single episode, unspecified. The facility did not provide a policy for Psychotropic Medication use when requested during the survey.
- Potential for harm · E2023-12-09 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to maintain resident rooms in a clean sanitary manner. This applies to 6 of 7 residents (R10, R11, R12, R13, R14 and R15) reviewed for homelike environment in a sample size of 15. Findings include: 1. On 12/7/23 at 11:00 AM, V14 (R10's daughter) stated, on 11/21/23, R10 used the bedside commode. The commode with urine & stool in it was left in the room for 3 days and it was cleaned on Monday, 11/24/23. On 12/7/23 at 11:00 AM, observed R10's walker was dirty and with cleanable stains. V14 stated, she asked the nursing staff and the housekeeping staff to clean it, and nobody did. 2. On 12/7/23 at 11:15 AM, observed R13's soiled clothing - a bedsheet, pajamas, shirt, socks and R13's sling used for mechanical lift, on the floor. 3. On 12/7/23 at 11:40 AM, R15 stated, on 12/5/23, R15 used her bedside commode. The commode with urine and stool in it was left in the room until 12/6/23, when it was cleaned. R15 stated, she asked the CNAs to clean it, yet nobody did. R15's MDS (Minimum Data Set) dated 11/22/23 showed R15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that staff donned appropriate personal protective equipment (PPE) when entering an isolation room. The facility also failed to post isolation signs on doors of residents who had been diagnosed with Covid 19. This applies to 3 of 4 residents (R4, R6, and R9) reviewed for infection control in the sample of 13. The findings include: Review of R4, R6, and R9 Covid 19 laboratory results on 11/22/23 documents they all tested positive for Covid 19 on 11/21/23. Review of the facility's isolation order summary show that R4, R6, and R9 are to be on strict contact/droplet isolation related to Covid. R4 and R9 are to be on Contact/Droplet isolation until December 2, 2023, and R6 until December 1, 2023. On November 28, 2023, at 10:35 AM, there were contact and droplet isolation signs posted on the door of R6's room. The sign shows that an N95, gown, gloves and a face shield or googles should be donned before entering the room. V8 CNA (Certified Nursing Assistant) went into R6's room and talked to R6 and turned his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-26 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide food that is appetizing, tasty and at the appropriate temperature. This applies to 5 of 92 residents (R10, R19, R26, R27, R343 and R344) reviewed for dietary services in a sample of 21. Findings include: Facility Resident Census and Condition of Residents (Form CMS--Centers for Medicare and Medicaid Services--672), dated 5/23/23, documents the total census was 92 residents and that one resident was on tube-feedings. 1. On 05/23/23 at 1:12 PM, surveyor observed R10's lunch plate untouched except for the fruit cup that she ate. R10 gave away the beef taco to another resident as she did not like it. The corn and rice were left on the plate. R10 stated, she cannot eat the corn and the rice as they are carbohydrates, and she is diabetic. R10 stated, she ate some cottage cheese that her daughter had left in the refrigerator. On 5/23/23 at 10:31 AM, V19 (R1's daughter) stated, she asked the facility to take out the carbohydrate from her meal trays, yet they still serve it to R10. V19 stated, if the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow contact isolation precautions, follow appropriate hand hygiene and sanitize glucometer after use. This applies to 9 of 9 residents (R5, R19, R20, R63, R71, R72, R77, R78 and R342) in a sample size of 21. Findings include: 1. R342's face-sheet printed on 5/25/23 showed R342 had diagnoses to include traumatic brain injury, respiratory failure, and pseudomonas aeruginosa. R342's Physician Orders for May 2023 included strict contact isolation for positive pseudomonas in the sputum. R342's care plan dated 5/20/23, showed, R342 had pseudomonas in the sputum and the interventions included 'isolation as per Physician Orders'. On 5/23/23 at 1:18 PM, V17 (Physiatrist) examined R342, removed her gown and gloves and left resident's room without doing any hand hygiene. On 5/23/23 at 1:20 PM, V18 (Medical Records personnel) entered R342's room without gown or gloves. On 5/24/23 at 9:40 AM, V16 (Housekeeping Personnel) came out of the room with gloves that he used to clean inside the room and touched the bottles 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 · D2023-05-26 · 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 ensure medications were administered as ordered by the physician. There were 34 opportunities with 2 errors resulting in a 5.88% error rate. This applies to 1 of 6 residents (R59) reviewed for medication administration in the sample of 21. The findings include: On 5/23/23 at 11:49 AM, V4 (LPN-Licensed Practical Nurse) was observed administering Quetiapine Fumarate 100mg (milligrams), 2 tablets and Quetiapine Fumarate 100 mg, half a tablet to R59. On 5/24/2023 at 8:10 AM, V5 (RN-Registered Nurse) was observed administering Olanzapine 5 mg, 1 tablet to R59. Interview with V2 (DON-Director of Nursing) on 5/25/2023 at 8:47 AM, V2 stated there is no order for Quetiapine Fumarate and Olanzapine. She stated the order for each medication was discontinued on March 20,2023. V2 stated she expects the nurse to compare the medication being given with the order. Interview with V8 (NP- Nurse Practitioner) on 5/25/2023 at 10:53 AM stated the orders for Quetiapine Fumarate and Olanzapine were discontinued on 3/20/2023 when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · D2023-05-26 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide mechanical soft and double portions diet as ordered by physician. This applies to 1 of 5 residents (R31) reviewed for diet in a sample of 21. The findings include: R31's POS (Physician Order Sheet) shows regular diet mechanical soft texture and double portions all meals. R31's MDS (Minimum Data Set) shows his cognition is intact. On 5/23/23 at 11:11 AM, R31 was observed curled up in bed lying on his side and appeared very thin. On 5/23/23 at 12:59 PM, 5/24/23 at 9:04 AM, and 5/24/23 at 12:55 PM, R31 was served general regular meal trays, instead of the physician ordered mechanical soft diet, and was observed attempting to eat the food from these trays. On 5/23/23 at 12:59 PM, R31 took one bite of the roasted corn and one bite of the Spanish rice and stated, that's all I can eat, I can't chew any of this, it's not soft. It feels like paper cuts in my mouth. R31 did not receive double portions on the 5/23/23 lunch tray. On 5/24/23 at 12:55 PM, R31 took one bite of the beef cubed steak and spit it back…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 before2022-04-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure resident's food was handled in a sanitary manner. This failure has the potential to affect 87 of 88 residents in the facility reviewed for sanitation. The findings include: The Resident Census and Conditions of Residents form CMS-672 shows on 4/11/2022 the facility census was 88. A facility provided dietary list shows one resident was not receiving food from the kitchen on 4/11/2022 he was NPO (nothing by mouth) On 4/11/2022 at 11:00 AM, V8 (Cook) was slicing Turkey for the noon meal. He had gloves on and picked up the Turkey breast with his gloved hands and began slicing Turkey. He was touching the top of the slicer to run the machine and then picking up the Turkey as it would slice and placing it in another pan for the meal service. He picked up the small pieces of the turkey with the same gloves on and then put them in another container to make the pureed and mechanical soft meats. At 11:40 PM, V8 picked up a pan of mechanical soft Turkey and divided half into another pan, without changing gloves or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-04-13 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide activities of daily living assistance for dependent residents for 5 of 22 residents (R20, R47, R184, R15, R136) in the sample of 22. The finding include: 1. On 04/11/22 at 9:55 AM, R20 stated there is one Certified Nursing Assistant for the whole floor on nights. It takes two people to do a mechanical lift transfer for me, so I sit in my chair for 4-5 hours waiting for two staff to transfer me. I sat in my dirty adult brief for at least three hours the other night. My shoulders and hips hurt from sitting in my chair for so long. R20's Minimum Data Set, dated [DATE] shows R20 is cognitively intact and requires extensive assistance of two person for transfers and toileting. On 04/13/22 at 10:30 AM, V2 Director of Nursing said residents are checked and changed every two hours and as needed. The facility's Activities of Daily Living Policy dated 5/2021 shows a program of activities of daily living is provided to prevent disability and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-04-13 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to off load a non-pressure wound to promote healing, failed to provide wound care to a non-pressure wound as ordered, and failed to address a resident's complaint of nausea for 4 of 22 residents (R57, R184, R15, and R136) reviewed for quality of care in the sample of 22. The findings include: 1. R57's Wound Evaluation document dated 4/4/22 showed a blister to the sole of R57's right foot near her heel. The blister measured 4.04 centimeters (cm) x 2.49 cm. The same document list under Treatment, the use of a heel suspension device. On 04/12/22 at 9:25 AM, V6 (Wound Care Doctor) said the blister on R57's right foot was a non-pressure injury. V6 stated the wound should be offloaded to promote healing. On 04/11/22 at 09:49 AM, R57 was sitting in a reclining wheelchair. The footrest of the reclining wheelchair was a L shape. R57's right foot was resting on the footrest. The sole/heel of R57's right foot was resting directly on the footrest. R57's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-04-13 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure menus were followed for residents on a pureed diet. This applies to 6 of 6 residents (R81, R57, R29, R21, R56, R75) reviewed for menus in the sample of 22. The findings include: The facility provided list shows R81, R57, R29, R21, R56 and R75 receive pureed diets. The facility provided menu for 4/11/2022 shows the following items will be served for the noon meal: Oven Roasted Turkey, Poultry Gravy, [NAME] Pilaf, Warm Spiced Carrots, and Strawberry Banana Pudding Parfait. The facility provided Pureed Strawberry Banana Pudding recipe shows sliced strawberries should be added to the banana pudding and then pureed. The noon meal service was observed continuously on 4/11/2022 from 11:00 AM until 12:47 PM. The Banana Pudding was placed into bowls by V10 (Dietary Aide), and Strawberries were placed on top. A separate batch of the pudding was then left without Strawberries on them while more were thawing to be pureed. Those bowls without Strawberries were then put on the cart and taken to serve to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-13 · 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 ensure a resident was treated in a dignified manner for 1 of 22 residents (R185) reviewed for dignity in the sample of 22. The findings include: On 04/11/22 at 9:44 AM, R185 stated I'm going home today. I can get better at home. I waited for hours for them to answer the call light one night and when they did, they told me to pee in my pants and they would change me. I feel degraded already having cancer, I don't need to be embarrassed further being told to pee in my pants. On 04/13/22 at 9:20 AM, V15 Licensed Practical Nurse stated it is not acceptable to tell a resident to just pee in their pants, you should assist the resident to use the bed pan or take them to the toilet. On 04/13/22 at 10:30 AM, V2 Director of Nursing stated R185 is alert and oriented and is able to communicate her needs and it is not acceptable for residents to be told to pee in an adult brief. The facility's Concern Form dated 4/11/22 from R185 shows resident stated Certified Nursing Assistant informed/instructed her to go ahead and pee in her pants…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · D2022-04-13 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to honor resident choices for 1 of 22 residents (R5) reviewed for choices in the sample of 22. The findings include: On 04/11/22 at 10:35 AM, R5 was in bed, in a hospital gown. R5 stated I like to get up early, get dressed, and be up in the dining room for breakfast. I'm still in bed at 25 minutes to 11. I don't like breakfast in bed. I talked to V1 Administrator and my family talked to V1 about my likes. They say so and so didn't show up for work as their excuses. I missed activities this morning because I'm in bed. On 04/11/22 at 12:15 PM, R5 was up in her wheelchair in her room. R5 stated I just got up finally. They said someone didn't show up, but they say that a lot. On 04/12/22 at 9:10 AM, R5 was in bed, in a hospital gown. R5's breakfast tray was on an overbed table. R5 stated here we are again, I am in bed to eat breakfast. I prefer to be up and dressed and at least in my chair. It's so hard to eat in bed, its awkward for me. On 04/13/22 at 10:30 AM, V2 Director of Nursing stated residents should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-04-13 · tag F0565 — failed to support the resident council — isolatedHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide a private and quiet space for the Resident Council monthly meetings. This applies to 1 of 1 residents (R15) reviewed for Resident Council in a sample of 22. The findings include: On 4/11/22 at 11:47 AM R15 stated, The resident council meetings are chaotic. They are noisy. This place does not have any private places for us to meet, and it is like I tell them and then the next month it is the same thing, do they forget? We tell them our concerns and people ask questions, but nothing changes, and nothing gets done about it. I have been the Resident Council President for 7 years and it has never been this bad. On 4/13/22 at 11:24 AM R15 stated, The last meeting was a joke. It was so noisy you couldn't hear anything. I finally just stopped talking and sat there. People were coming in and out of the kitchen and pushing carts through the dining room. I don't know if I even want to be President anymore. On 4/13/22 at 09:12 AM V13 (Activity Director) stated, The Resident Council meeting is held every month. The last Monday…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · D2022-04-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide incontinence care for 1 of 7 residents (R184) reviewed for incontinence care in the sample of 22. The findings include: On 04/11/22 at 10:54 AM, R184 stated last night I had a messy adult brief at dinner, and I had to wait until 11 PM to get changed. I got a rash from being in the wet adult brief. Today physical therapy got me up and changed at 8 AM, and at 9 they got me into the chair and at 1030 AM they put me back to bed. I was not changed since I got up. On 04/11/22 at 12:58 PM, V12 Certified Nursing Assistant was providing incontinence care and removed a urine-soaked brief from R184. R184 had redness on both sides of her groin area and vaginal area. On 04/13/22 at 10:30 AM, V2 Director of Nursing said residents are checked and changed every two hours and as needed. R184's Minimum Data Set, dated [DATE] shows R184 is cognitively intact, requires assistance with activities of daily living and is always incontinent of bowel and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-04-13 · 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 ensure a resident's oxygen was humidified and administered at the prescribed settings for 1 of 5 residents (R51) reviewed for oxygen in the sample of 22. The findings include: On 04/11/22 at 10:22 AM, R51 was in bed with a nasal canula on. R51's oxygen concentrator was set a 4 Liters and the water bottle was empty. V15 Licensed Practical Nurse staff came into room and stated, I will change this. On 04/11/22 at 12:32 PM, R51 was up in her wheelchair in the dining room. R51's portable oxygen tank was set at 3 liters. On 04/11/22 at 01:40 PM, R51 was up in her wheelchair in tv room with the portable oxygen tank still set at 3 liters. On 04/12/22 at 08:45 AM, R51 was in bed on 4 liters of oxygen via nasal cannula. The water bottle on the oxygen concentrator was empty. On 04/12/22 at 12:34 PM, R51's oxygen concentrator water bottle remained empty, resident was on 4 liters oxygen via nasal cannula. On 04/13/22 at 9:17 AM, R51 was in bed on 4 liters oxygen via nasal cannula. The water bottle on the oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · D2022-04-13 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that a resident received her pain medication in a timely manner. This applies to 1 of 22 residents (R67) reviewed for pain in a sample of 22. The findings include: On 4/11/22 at 2:00 PM R67 complained of pain to legs and lower back. R67 stated, They are out of my pain medication. They were out last night, and they are still out this morning. My pain is about an 8 right now. On 4/11/22 at 2:15 PM, V14(LPN) Licensed Practical Nurse confirmed that R67's Norco (Analgesic) was out then stated that she would check on it. V14 worked the PM shift on 4/10/22 and the day shift on 4/11/22. V14 stated, I think some of the nurses are just too lazy to reorder the medication. On 4/13/22 at 9:30 AM V11(RN) Registered Nurse showed Surveyor R67's Norco Medication Card dated 4/12/22. V11 confirmed that R67 was given a dose of Norco at 6:00 AM on 4/13 and stated, she takes it pretty often. R67's April Medication Administration Record shows that R67 has…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-04-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to accurately enter orders into the electronic medical record and failed to administer medication as prescribed for 3 of 22 residents (R57, R74, and R47) reviewed for pharmacy services in the sample of 22. The findings include: 1. R57's Order Summary Report printed on 4/11/22 showed an order for Oseltamivir Phosphate (medication to treat the flu) to be given for 14 days. The order had a start date of 3/21/22 and had no end date. R57's Medication Administration Record (MAR) showed the Oseltamivir Phosphate order was started on 3/21/22 and had a discontinued date of 4/11/22 (21 days after the start date). R57's March and April MAR indicated R57 received 20 doses of Oseltamivir Phosphate. A pharmacy Delivery Manifest showed R57 had 14 doses of Oseltamivir Phosphate delivered to the facility. 2. R74's Order Summary Report printed on 4/11/22 showed an order for Oseltamivir Phosphate to be given for 14 days. The order had a start date of 3/21/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 · D2022-04-13 · 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
Based on observation, interview, and record review the facility failed to ensure the needle on an insulin pen was primed prior to administration of the medication to ensure the correct dose was being administered. This applies to 1 of 4 residents (R137) reviewed for medications administration in a sample of 22. The findings include: On 4/12/22 at 8:00 AM V14 (LPN) prepared R137's Humalog Insulin dose of 10 units. V14 opened a new Humalog Insulin pen, attached the needle, turned the dial to 10 units and administered the insulin into R137's right abdomen. When completed Surveyor asked V14 why she did not prime the needle prior to administration. V14 replied, I've noticed when I do that (prime) then I see insulin on the skin. This vial was new, and I didn't see any air in the vial, so I didn't think I needed to prime it. V14 then asked Surveyor if she was supposed to prime the needle only when the insulin pen was new. V14 then applied a clean needle to the insulin pen, turned the dial to 2 units, primed the needle, removed and discarded that needle and put the insulin pen back into 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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to BRIA HEALTH SERVICES — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 1.4 | +1.6 vs chain |
| Health inspection | 4 of 5 | 1.8 | +2.2 vs chain |
| Staffing | 1 of 5 | 1.2 | -0.2 vs chain |
| Quality measures | 2 of 5 | 2.5 | -0.5 vs chain |
The other 9 homes this chain runs (chain average 1.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| WEISS, NATAN | Individual | W-2 MANAGING EMPLOYEE | since 06/01/2011 |
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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 146067. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-26, 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.