Bria Of Godfrey

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

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.

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.

63.0% 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 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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.

Staffing

How full it usually is: this home is certified for 68 beds and averages 50.0 residents a day — about 74% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.25 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 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 2.83 hrs/resident/day on weekends vs 3.42 on weekdays — 17% thinner on weekends. RN hours go from 0.69 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 77% 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 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.

41 citations, most serious first. The 22 most serious are shown; the remaining 19 are one tap away and print in full.

• Actual harm · G2025-12-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure a resident with history of falls was assessed appropriately by nursing staff after a fall. This failure would have resulted in a reasonable person enduring pain for over a day due to a rib and clavicle fracture until nursing staff was notified completed an assessment. Findings include:R2's December 2025 Physician Order Sheet (POS) documents a diagnosis of Parkinson's disease with dyskinesia, with fluctuations, chronic respiratory failure, severe protein calorie malnutrition, traumatic subarachnoid hemorrhage without loss of consciousness, abnormal weight loss, delirium due to physiological condition, and anxiety disorder. R2's Minimum Data Set (MDS), dated [DATE], document R2 was severely impaired for cognition for activities of daily living. R2 uses a wheelchair and requires substantial/maximal assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R2's Care Plan: Falls…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-22 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to prevent a significant medication error in 1 of 6 residents (R3) when reviewed for medication administration in the sample of 6. This failure resulted in R3 being admitted to the hospital with a principal problem of Accidental Drug Overdose. Findings Include: R3's Progress Note, dated 4/17/25 at 6:59 PM, documents the following: This Nurse recognized that I administered a wrong medication to the resident. Res. (Resident) has NKA (No Known Allergies). Res sent to ER (Emergency Room) for evaluation. NP (Nurse Practitioner, Administrator, and D.O.N (Director of Nurses) all made aware. ER MD (Medical Doctor) aware. R3's Progress Note, dated 4/18/25 at 5:50 PM, documents the following: Update resident admitted with hypoglycemia and medication error. Resident stable and alert at this time. R3's Progress Note, dated 4/20/25 15:02 PM, documents the following: Resident returned to facility via ambulance at 14:55 (2:55 PM). R3's Medication Error Report, dated, 4/17/25, documents the following: Occurred on 4/17/25 at 6:50 PM,…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-03-04 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure enteral gastrointestinal feedings and care were provided as ordered for 3 of 3 (R2, R1, R3) residents reviewed for enteral feeding management. This failure resulted in R2 requiring hospitalization for treatment of aspiration pneumonia related to food regurgitation. Findings include: 1. R2 was admitted to the facility on [DATE], with diagnoses of diffuse traumatic brain injury with loss of consciousness, severe protein-calorie malnutrition, dysphagia, and acute respiratory failure. R2's Minimum Data Set (MDS), dated [DATE], documented he is severely cognitively impaired and dependent on staff to assist with all mobility. R2's Care Plan, dated 5/30/24, documented R2 is at risk for complications related to tube feeding with a goal to remain free of aspiration pneumonia throughout next review. Interventions for this care plan are documented to be, in part, administer tube feedings as ordered. R2's Progress notes on 2/20/25 at 7:33 PM…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-02-28 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have physician prescribed narcotic pain medication for 1 of 3 residents (R2) reviewed for pain. This failure resulted in the resident experiencing severe pain, becoming incontinent of bowel and bladder, and displaying agressive behaviors. Findings include: R2's Undated Face Sheet documents he was admitted to the facility on [DATE], with diagnoses including spinal stenosis, pain thoracic spine, low back pain, and chronic pain syndrome. R2's Care Plan documents, focus pain alteration in comfort related to the advanced disease process, chronic physical or psychological disability, musculoskeletal, neurological issues due to diabetic neuropathy and osteoarthritis of the right hip. Goal: resident will not experience a decline in overall function r/t (related to) pain through next review. Will maintain adequate levels of comfort as evidence by no s/s (signs or symptoms) of unrelieved pain or distress, verbalizing satisfaction or expressing with…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to assure appropriate fall interventions were in place and supervise 1 of 4 (R3) residents reviewed for falls and safety in the sample of 4. This failure resulted in R28 sustaining multiple falls, bruising of varies stages of healing, and a laceration to R3's head. Finding includes: 1. R3's admission Record, not dated, documents R3's admission date 5/30/2024. It also documents Hemiplegia and Hemiparesis following Cerebral Infarction Affecting left non-dominant side, Type 1 Diabetes Mellitus with other specified complication, Dysphagia following cerebral infarction, Cerebral Infarction, unspecified, Chronic Obstructive Pulmonary Disease, unspecified, Difficulty in walking, not elsewhere classified, weakness, unsteadiness on feet, Displaced Intertrochanteric Fracture of Right femur, Chronic pain syndrome, Unspecified History of falling, and polyneuropathy, unspecified, listed as diagnoses. R3's Baseline Care Plan, dated 5/30/2024, documents R3 is at high risk for falls. It continues, Interventions: A. Call light within reach B.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-07-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet the residents' need for assistance with personal care, bathing, showers, and oral care, and failed to ensure residents were provide an effective way to call for help for 5 of 7 (R23, R41, R45, R150, R151) residents reviewed for ADLs (Activities of Daily Living) in the sample of 34. This failure resulted in R151 feeling frightened and scared. Findings include: 1. R151's admission Record, not dated, documents R151 was admitted on [DATE], and lists Type 2 Diabetes with diabetic Polyneuropathy, Hemiplegia, and Hemi paresis following Cerebral Infarction affecting Left Non-Dominant Side as diagnoses. R151's Interim Baseline Care Plan, effective date 7/12/23, documents, B. Falls, 3. Intervention Call light within reach. R151's admission Observation, effective date 7/12/23, documents R151 is responding to environment, alert to person, place, and time. R151's Call light Ability Screen, effective date 7/12/2023, documents R151 is able to use…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-07-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide wound care, including changing dressings, and failed to perform skin and wound assessments for 3 of 6 residents (R23, R32, R150) reviewed for pressure ulcers in the sample of 34. This failure caused R23 to develop an unstageable pressure sore on his left heel, that went unnoticed by the staff, with no Physician Orders or treatment. Findings include: 1. R23's admission Record, undated, documents R23 was admitted to the facility on [DATE]. R23's Electronic Medical Record, documents R23's Diagnosis include: COPD (Chronic Obstructive Pulmonary Disease), Emphysema, Type 2 DM (Diabetes Mellitus), Cerebral Infarction, Lumbago with Sciatica, Gastrostomy, Convulsions, Major Depressive Disorder, Malignant Neoplasm of lung, ASHD (Atherosclerotic Heart Disease), Anemia, Adult Failure to Thrive, MI (Myocardial Infarction), HTN (Hypertension), Hyperlipidemia, and Malignant Neoplasm of Pelvic Bones, Sacrum, and Coccyx. R23's Care Plan, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-07-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safe transfers and progressive interventions for 3 of 4 residents (R30, R32, and R35) reviewed for falls in the sample of 34. This failure resulted in R32 falling and fracturing his right hip requiring surgical repair. Findings include: 1. R35's electronic medical record documents R35 has had 5 falls from 2/1/2023-6/25/2023. Fall report, dated 2/1/2023, documents, At 18:15 PM, (R35) was getting off the toilet and had pulled up his (incontinence brief), pants still down to knee, he fell and was lying on right side in doorway of bathroom. He stated he did not hit his head. No injury noted. Interdisciplinary Team (IDT) meeting, 2/9/202, documents, RCA (root cause analysis) resident on toilet and fell pulling up pants, all previously care planned intervention in place and adding education staff to stay with resident while using restroom. Care plan reviewed and updated. R35's record documents R35 had a fall 3/10/232023 at 21:52 PM,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-07-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely and complete incontinence and catheter care for 5 of 5 (R23, R41, R42, R45, 150) residents reviewed for incontinent care in a sample of 34. This failure resulted in R42 feeling angry, sad, alone, and like no one wants to take care of her. Findings include: 1. R42's Care Plan, dated 5/25/23, documents, skin: (R42) has potential for skin integrity issues such as pressure ulcers/injuries as she always is incontinent of bowel and bladder and requires limited assistance with the bed mobility ADL. She has diagnoses of DM type 2, anemia, and morbid obesity due to excess calories. R42's Minimum Data Set, (MDS), dated [DATE], documents R42 is cognitively intact, always incontinent of bowel and bladder, and is totally dependent on 1 staff for toileting. On 7/18/2023 at 12:50 PM, V2, Director of Nursing, and V5, Restorative Aide, assisted R42 with incontinent care. R42 was incontinent of urine and bowel. V5 opened R42's incontinent…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-09-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to prevent the formation of pressure ulcers, failed to treat pressure ulcers as ordered by the physician and failed to provide pressure relief for residents with pressure ulcers for 2 of 2 residents (R39, R33) reviewed for pressure ulcers in the sample of 26. This failure has resulted in R39 developing an unstageable, pressure ulcer to the right knee. Findings include: 1. R39's admission Record, documents R39 was admitted on [DATE], with diagnoses of: pressure ulcer right hip, displace avulsion fracture of left ilium, nondisplaced zone I fracture of sacrum and, nondisplaced fracture of shaft of right clavicle. R39's Care Plan, dated 6/28/22, documents (R39) has both potential for and actual impairment to skin integrity r/t (related to) fragile skin, combative behaviors and was admitted with a non-blanchable discoloration to the right hip area which was noted to be a Stage one pressure injury. He was seen by the wound specialist and he noted…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide assistance, supervision, and implement progressive interventions to prevent falls for 2 of 6 residents (R38, R196) reviewed for falls in the sample of 26. This failure resulted in R38 falling and sustaining a laceration to the back of the head, requiring 5 staples. Findings include: 1. R38's admission Profile, print date of 9/28/22, documents R38 was admitted on [DATE], and has diagnoses of: difficulty walking, unsteadiness on feet, repeated falls, Dementia, and Parkinson's Disease. R38's Fall Risk Evaluations, dated 8/24/22, 8/27/22, 8/31/22 and 9/5/22, all document R38 is a high fall risk. R38's Minimum Data Set (MDS), dated [DATE], documents R38 is severely cognitively impaired and requires limited assistance of 2 staff members for bed mobility, extensive assistance of 2 staff members for transfer and toilet use, limited assistance of 1 staff member for walking in room and on the unit and extensive assistance of 1 staff member…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-09-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assist with feeding, monitor weights, and implement progressive interventions to prevent weight loss for 1 of 3 residents (R40) reviewed for weight loss in a sample of 26. This failure resulted in R40 having a significant weight loss of 10% in 1 month and 17 % in 3 months. Findings include: R40's admission record, dated 09/29/2022, documented an admission date of 6/07/2022, with diagnoses of stroke, dysphagia, other lack of coordination, and major depressive disorder. R40's Care plan, dated 06/23/2022, documented, Provide one-to-one staff intervention to promote proper nutritional intake. It continues, Offer between meal snacks & meal substitutions, as appropriate. Offer the resident a bedtime snack. R40's Minimum Data Set (MDS), dated [DATE], documented her cognition was moderately impaired, and she required limited assistance of 1 staff member for eating. R40's Dietary Evaluation, dated 08/30/2022, V18, Dietician, documented, 85 (year…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-05 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  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 a supporting diagnosis for a prescribed antipsychotic for 1 of 6 residents (R6); reviewed for chemical restraints in a sample of 7.Findings include:R6's Facesheet with a print date of 5/4/26, documented she was admitted to the facility on [DATE] and was discharged on 2/5/26. R6's Facesheet also documented she was admitted with the following diagnoses of fracture of right tibia, fracture of upper and lower end of right fibula, alcohol abuse, insomnia, and major depressive disorder.R6's Minimum Data Set (MDS), dated [DATE], documented she was cognitively intact.R6's Medication Order Audit documented V25, Licensed Practical Nurse (LPN), placed an order on 1/16/26 at 9:44 PM for Quetiapine Fumarate oral tablet 50 mg (milligrams) to be given 1 tablet by mouth two times a day for prophylaxis. Additional information on the order documented in red letters Alert? Black Box Warning! R6's Order details on Quetiapine also documented under notes to obtain…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-12-19 · tag F0610 — failed to investigate and act on abuse reports — widespread
  Respond 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 ensure the alleged perpetrator of an abuse allegation did not have access to residents when an allegation of abuse occurred, and failed to ensure all abuse allegations were investigated. This has the potential to affect all 50 residents living in the facility. Findings include:R10'S Physician Order Sheet (POS) for December 2025 documents a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Type 2 diabetes mellites with other specified complications, muscle weakness, acquired absence of left leg below knee, major depression disorder, single episode, several without psychotic features, and dependence on wheelchair. R10's Minimum Data Set, dated [DATE], document R10 has an impairment on both his upper and lower extremity on one side. R10 was cognitively intact for decision making of activities of daily living, uses a wheelchair and needs substantial assistance for most ADL's (activities of daily living).…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-10-15 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the correct dose of physician prescribed medication (Lantus insulin) in 1 (R2) of 3 residents reviewed for medication errors in the sample of 3. Findings Include:R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has medical diagnoses of Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, and Anxiety Disorder.R2's Minimum Data Set (MDS), dated [DATE], documents R2 is severely cognitively impaired.R2's Previous Physician Order, dated 8/4/2025 at 9:27 AM ,documents Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 27 unit subcutaneously at bedtime for diabetes mellitus.R2's Nurses Notes, dated 9/23/2025 at 10:02 PM, documents, The other Nurse stated she gave resident 27 units of Lantus, I told Nurse res (resident) was mine and already had insulin. Telehealth Medical Doctor (MD) aware stated check fasting blood sugar (fsbs) every hour. Res was given snack and glucose gel. Sugar is 231, however res is being…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision and interventions to prevent falls for 1 of 3 residents (R2) reviewed for falls. Findings include:R2's undated face sheet documented she was admitted to the facility on [DATE], with diagnoses including anxiety, hyperlipidemia, hypertension, altered mental status, and dementia.R2's Minimum Data Set (MDS), dated [DATE], documented she has memory problems and is moderately cognitively impaired. The MDS documented R2 requires set-up assistance for eating and requires staff supervision for all other activities of daily living (ADL's). R2's care plan, dated 7/15/25, documented R2 is a currently at a high risk for falls with a goal that she will remain free of falls. Her interventions for this care plan include: encourage appropriate use of wheelchair, evaluate multiple falls to determine any patter, fall risk assessment quarterly and as needed, keep bed in lowest position, keep frequently used items within reach,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-05 · tag F0917 — isolated
  Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
  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 each resident had a closet with shelf space for 1 of 6 residents (R2) reviewed for closet space in the sample of 6. Findings include: On 6/5/2025 at 12:48 PM, V8, Family of R2, stated, (R2)'s room was at the end of the hall. There was a small space, but no actual closet, and from the ceiling the facility had a PVC pipe running from one end to the other then forming a box, that I guess that was where my mom was supposed to hang her clothes. There was no shelving, and we went out and bought her a curtain and put it on tension rod, so it would be more homelike for her. It was not homelike before that, trust me on that one. (R2) had a single room but there was no closet, just this space with the PVC pipe. There was no portable wardobe just the PVC pipe for the clothes. On 6/5/2025 at 1:14 PM, R2's former room did not contain a built in wardrobe. There was a small space boxed in a square, with white PVC pipe running all the way across the ceiling. At one end of the PVC pipe was a square made out 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-09 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to administer medications as ordered by the physician in 2 of 4 residents (R2, R3) reviewed for pharmacy services in the sample of 4. Findings include: 1. On 4/8/25 at 11:55 AM, V5, R2's Daughter, stated R2 had not been receiving her daily medications. R2's Face sheet, undated, documents R2 has the following diagnoses: Three Part Fracture of the Left Humerus, COPD (Chronic Obstructive Pulmonary Disease), Neuropathy, MDD (Major Depressive Disorder), CHF (Congestive Heart Failure), Cardiac Pacemaker and Defibrillator, History of Falling, Arthropathy, Gout, HTN (Hypertension), Low Back Pain, and Chronic A. Fib (Atrial Fibrillation). R2's MAR (Medication Administration Record), dated 4/1/25 through 4/30/25, documents the following physician orders, dated 4/1/25: Spironolactone Oral Tablet 25 MG (Milligrams) give 0.5 tablets by mouth one time a day for High Blood Pressure; Sertraline HCl (Hydrochloride) Oral Tablet 25 MG give 1 tablet by mouth one time a day for Depression; Furosemide Oral Tablet 40 MG give 1 tablet by mouth 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-31 · tag F0622 — isolated
  Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's discharge was complete, including housing, Durable Medical Equipment (DME), and medications needed prior to discharging the resident to the hospital, and then failing to accept the resident back to the facility upon hospital discharge for 1 of 4 residents (R2) reviewed for transfer and discharge requirements. This failure resulted in R2 having to find a place to live, not having appropriate DME, and not having medications available as needed. The findings include: R2's admission Record, dated 3/26/25, documents R2 was admitted to the facility on [DATE], and was discharged to the hospital on 3/5/25. R2's diagnosis include: Spinal stenosis cervicothoracic region, Type 2 Diabetes Mellitus (DM), nicotine dependence, rhabdomyolysis, suicidal behavior, major depressive disorder, alcohol use, hypothyroidism, hypertension (HTN), bipolar disorder, mood affective disorder, encephalopathy, spondylosis with myelopathy, and osteoarthritis. R2'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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-14 · tag F0740 — failed to provide behavioral / mental-health care — pattern
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess 4 of 4 residents (R2, R3, R11, R12) for risks of self-harm upon their admission to the facility. This failure has the potential to affect those residents from self- harm. Findings include: 1.R2's Face Sheet undated documents he was admitted to the facility 7/26/24, with diagnoses of Major Depressive Disorder, Cerebral, Infarction, Unspecified, Restless and Agitation, Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance and Anxiety, and Vascular Dementia, Unspecified Severity, with Agitation. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has moderate cognitive impairment, reports 12-14 days (nearly every day) of feeling bad about himself or that he is a failure or that he has let his family down; is feeling down, depressed, or hopeless. R2's Psychiatric Progress note, dated 8/27/24, from the area psychiatric services documents R2's family reported R2 threatens family and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-11-14 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer 4 of 4 residents ( R2, R3, R5, R13) medications as prescribed and according to the facility's policy and procedures. This failure resulted in residents receiving their medications two hours or more after the scheduled times. Findings include: 1. R2's Face Sheet undated documents he was admitted to the facility 7/26/24, with pertinent diagnoses of Major Depressive Disorder, Cerebral, Infarction, Unspecified, Restless and Agitation, Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood disturbance and Anxiety, and Vascular Dementia, Unspecified Severity, with Agitation. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has moderate cognitive impairment, reports 12-14 days (nearly every day) of feeling bad about himself or that he is a failure or that he has let his family down; is feeling down, depressed or hopeless. R2's Physician Order Summary, dated October 2024, documents R2'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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to utilize physician ordered pressure relieving devices and or treatments for two of three residents (R3, R35) reviewed for pressure ulcers in the sample of 31. Findings Include: 1. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is severely cognitively impaired. R3's MDS also documents need substantial to maximum assistance in rolling from left to right. R3's Braden Scale, dated 6/28/24, documents R3 has a moderate risk of developing pressure ulcers. R3's Physician Order Sheet (POS), dated 7/28/24, documents, (pressure Relieving boots) to bil (bilateral) feet when in bed, for sore heels. R3's Skin Care Plan intervention documents protect heels initiated on 2/28/24. On 08/13/24 at 2:20 PM, R3 was laying in bed and her heels were directly on the bed. On 8/15/24 at 2:20 PM while watching catheter care, R3 did not have on pressure relieving boots and her bilateral heels were red. R3's heels were lying flat on the bed. On 8/15/24 at 3:15…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$209,961 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $39,865 — penalty dated 2025-12-19
• $98,228 — penalty dated 2025-08-13
• $12,425 — penalty dated 2025-04-22
• $17,713 — penalty dated 2025-02-28
• $41,730 — penalty dated 2024-04-26
• Medicare payment denial — starting 2025-09-10 for 15 days

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

Part of a chain

This home belongs to 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 →

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

CMS files one row per role, so the 17 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $186K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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