Briar Place Nursing

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.

61.8% 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 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 63.2% 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 38 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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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.

Staffing

How full it usually is: this home is certified for 232 beds and averages 219.4 residents a day — about 95% occupied, or roughly 13 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 1.90 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.22 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 1.70 hrs/resident/day on weekends vs 1.98 on weekdays — 14% thinner on weekends. RN hours go from 0.28 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.

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

Inspection trend

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.

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.

50 citations, most serious first. The 19 most serious are shown; the remaining 31 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-07-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to secure the physical environment (window) in R1's room and implement appropriate precautions for a resident with a history of elopement risk, high suicidal risk, high risk per criminal background/ behavioral history, and assessed as being unsafe in the community unsupervised for one resident (R1) of three residents reviewed for elopement. This failure resulted in R1 removing the stationary window brackets that prevent the window from opening in his room, jumping out of the window, and eloping through the open back gate of the facility undetected by staff.The immediate jeopardy began on 7/3/25 at 10:28 PM, when R1 removed the stationary window brackets that prevent the window from opening in his room, jumped out of the window, and eloped through the open back gate of the facility undetected by staff. V3 DON Director of Nursing and V27 Regional Director of Operations were notified of the immediate jeopardy on 7/17/25 at 2:42 PM. The surveyor confirmed by…

  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
• Immediate jeopardy · Jcited before2024-04-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to effectively supervise a resident with history of drug abuse. This deficient practice affects one resident of three residents reviewed for change in condition. R28 had multiple incidents of noncompliance for bringing in contraband and R28 tested positive for cocaine once during R28's stay in the facility. R28 expired on 12/2/23 in the facility with cause of death as combined drug toxicity: Drug fentanyl Acetyl despropionyl fentanyl raised to the level of an Immediate Jeopardy. The Immediate Jeopardy began on 12/2/23 when R28 was found to be unresponsive at the bedside without breath. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/12/24 at 10:18am. The surveyor confirmed by onsite observation, interview and record review that the immediacy was removed on 4/18/24, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings…

  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 · G2025-09-04 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy by not protecting a resident from financial exploitation. This failure resulted in mental anguish and helplessness among 1 of 4 residents (R2) reviewed for theft and abuse in a sample of 4.The findings include:R2 is a [AGE] year-old female who was admitted on [DATE], and is independent in cognitive skills for daily decision-making, as per the Minimum Data Set (MDS) dated [DATE].On 9/2/25 at 12:05 PM, R2 stated, I originally had $1200 in my account, and I ran out $800 out of $1,200. I didn't give my bank card to anyone. Someone stole my card. The facility received my card through the mail, and I don't know why they left my mail under my pillow while I was admitted to the hospital. Somebody stole my card and used it in the neighborhood store. I am worried about my financial security here, and I don't know what to do. I didn't authorize anybody to buy stuff for me. When I returned from the hospital, I…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-20 · 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 one resident (R85) with adequate supervision during a shower. This resulted in R85 experiencing a seizure which led to her arm getting stuck in the handrail causing her to fracture her humerus. Findings Include: R85 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R85 has multiple diagnoses including but not limited to the following: Epilepsy, right humerus fracture, bipolar disorder, paranoid schizophrenia, mood disorder, anxiety, pain, and depression. Facility Reported Incident with date of 10/9/24 states in part but not limited to the following: R85 noted in shower room with right arm between shower rail and wall, R85 noted with pain, shortening, and abnormal rotation to right arm. R85 transferred to hospital for further evaluation and treatment. Hospital records dated 10/10/24 shows R85 arrived at the hospital from facility after an unwitnessed seizure in the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-20 · 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, interviews, and record review the facility failed to follow their pain management program when they failed to accurately assess R182's pain level and to ensure R182's pain was managed in a timely manner, four days after neck surgery to repair herniated discs. This failure resulted in R182 not receiving effective pain medication while experiencing severe and unbearable pain for an extended period of time, 9/10 on a pain scale of 0-10, in addition to suffering through periods of uncontrolled anxiety as a result of the prolonged severe pain. Findings include: R182 is a [AGE] year-old resident of the facility with medical diagnosis listed in part, but not limited to idiopathic peripheral autonomic neuropathy, hypertension, type 2 diabetes, hyperglycemia, and bipolar disorder. Per a progress note dated 10/21/2024 at 7:36 PM by V25 (Nurse Practitioner), R182 was hospitalized from [DATE] to 10/19/2024 for a C3-C7 decompressive laminectomy and posterior cervical fusion to repair herniated discs. On…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a vulnerable resident (R6) was free of physical abuse inflicted by staff. This failure resulted in R6 sustaining multiple injuries including a closed head injury and contusions (bruising) of the right thumb and forearm. Findings include: R6 is [AGE] years old and admitted to the facility 1/19/24 with diagnoses that include schizoaffective disorder, bipolar disorder, and other mental health disorders. According to the minimum data set, R6 is alert, however, is assessed to have mild cognitive dysfunction. Facility reported incident of 8/21/24 described an altercation with R6 and V15 a Certified Nursing Assistant (CNA) during the evening (3pm-11pm) shift. According to nursing progress notes, V16 LPN witnessed V15 CNA hitting R6 while in bed. V16 immediately intervened by removing V15 from the room and assessed R6 for injuries. R6 was transferred to the hospital and returned in the early morning with diagnoses of a closed head injury,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gdisputed · IIDR2024-08-29 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide detailed written notice 30 days prior to the discharge for one resident (R1) by failing to allow R1 to return to the facility while being accounted for on a facility issued community pass. This failure resulted in R1 not being properly discharged and being without medical care and medications for a month before getting a new primary care physician. Findings include: R1 is a [AGE] year old male and admitted to the facility 12/22/23 with diagnoses that included cerebral infarction, diabetes, asthma, hypertension, and substance abuse. On 8/20/24 at 4:09PM, R1 was interviewed over the phone and said that they were discharged from the facility on 7/27/24 without written notice. R1 explained that they were given a white pass which gives permission to leave the facility supervised overnight from 7/27/24 to 7/29/24. R1 said that his sister came to the facility to sign R1 out on 7/27/24, and R1 was allowed to leave. Shortly after leaving, the manager 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-29 · 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 and record review, the facility failed to restrict independent community access to a resident (R3) who was known to be refusing psychiatric/medically necessary medication and exhibiting active delusions and hallucinations. This failure resulted with R3 going out for a walk unsupervised and not returning to the facility. R3 was found three days later by local law enforcement, lying on the ground in the community, and taken to the emergency room where R3 was assessed with active psychosis. Findings include: R3 is a [AGE] year old female who originally admitted to the facility 4/30/2019 and has diagnoses that include schizoaffective disorder-bipolar type, generalized anxiety disorder, hypertension, and diabetes. The list of medical problems also includes a history of experiencing hallucinations and suicidal ideations. R3 is a ward of the state and has been appointed with having a state guardian since 9/26/1988. Progress notes were reviewed and indicated R3 has demonstrated a history of delusional…

  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 interviews and record reviews, the facility failed to have adequate supervision and interventions in place to keep residents assessed to be at risk for falls, free from injury. These failures applied to two (R133 and R302) of two residents reviewed for accidents and supervision and resulted in (R133) having a fall with head injury that required three sutures and resulted in R302 having an accident which resulted in a mid collar bone fracture. Findings include: R133 is a [AGE] year old male who was admitted to the facility 1/27/22 with diagnoses that include Dementia, cognitive communication deficit, lack of coordination and anxiety disorder. According to Minimum Data Set assessment dated [DATE], R133 has a BIMS of 03 indicating significant cognitive dysfunction. R133 also has a functional status requiring supervision by staff for walking. Fall incident report dated 9/23/22 indicated that R133 lost his balance and fell on his left side while trying to walk the hallway. R133 sustained a bleeding injury to…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-25 · tag F0559 — pattern
  Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
  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 notification of room and roommate changes were documented, failed to ensure family was notified of the room change, and failed to ensure residents received written notice including the reason for the change before the room or roommate change. These failures affected four (R1, R5, R6, and R7) residents reviewed for residents' rights in the total sample of 7 residents. Findings include:R1's admission Record documented that R1's diagnoses include but are not limited to Type 2 Diabetes Mellitus, major depressive disorder, and delusional disorder, and COPD (Chronic Obstructive Pulmonary Disease). R1's contact includes V9 (Resident Family member # 1). Contact Type: POA (power of attorney). R1's census list documented that R1 had a room change on 03/28/2026. R1's (02/25/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 14. Indicating R1's mental status as cognitively intact. R1's (Effective Date Range: 03/20/2026 to 03/28/2026) progress…

  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 · D2025-09-11 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow physician orders and failed to follow the facility community pass policy after no credible evidence of contraband was found for one (R72) resident. This failure affected one resident (R72) in a sample of 72 residents. Findings include:R72 is [AGE] years of age with diagnoses include not limited to: Alcohol Abuse, Anxiety Disorder, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Post- Traumatic Stress Disorder, Chronic, Suicidal ideations, Anemia, Unspecified, Insomnia, Unspecified, Other Psychoactive Substance Abuse, Uncomplicated, Schizophrenia, UnspecifiedSection C - Cognitive Patterns (7/6/2025) documented BIMS 15 (cognitively intact)R72's physician orders document an active physician order for independent community pass.R72's Community Survival Skills Assessment documents (in part) Effective 9/9/2025 at 08:51 9. Documents 2. Cannot Determine B. Recommendations and Outcomes 1. Recommendations 2. The resident does not appear to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-04 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on the interview and record review, the facility failed to comply with privacy and confidentiality requirements when delivering mail to residents. This applies to 1 of 4 residents (R2) reviewed for privacy and confidentiality with mail delivery in a sample of 4.The findings include:On 9/2/25 at 12:05 PM, R2 stated, The facility received my card through the mail, and I don't know why they left my mail under my pillow while I was admitted to the hospital. Somebody stole my card and used it in the neighborhood store.On 9/3/25 at 9:10 am, V6 (Social Service Director) stated, Activity staff are usually responsible for delivering the mail to residents. If a resident is not present, they are required to give the mail to social services for secure storage. I cannot explain why, in this instance, the activity staff left the mail under R1's pillow when she was not present. The correct procedure is to return the mail to me for safekeeping, not to leave it in the resident's room.On 9/3/25 at 12:20 PM, V9 (Activity Director) stated, I honestly do not remember the date I delivered R2's mail…

  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 · D2025-08-07 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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 upon record review and interview the facility failed to follow policy procedures and failed to ensure that the advance directives care plan was correct for one of four residents (R4) reviewed for change in condition.Findings include:R4's ([DATE]) POLST (Practitioner Orders for Life-Sustaining Treatment) Form states No CPR (Cardiopulmonary): Do Not Attempt Resuscitation. R4's ([DATE]) POS (Physician Order Sheet) includes Do Not Resuscitate. R4's care plan (revised [DATE]) states Advance Directive - Full Code [which is incongruent with R4's POLST & POS]. On [DATE] at 2:33pm, surveyor inquired about R4's current code status V6 (Director of Nursing) stated He's a DNR (Do Not Resuscitate). Surveyor inquired if R4's ([DATE]) advance directive care plan states DNR V6 reviewed the care plan and responded He (R4) has full code, it was revised but it's not accurate. It looks like the information that we (facility) have on advance directive code status is not accurate, he's technically a DNR this needs revised. 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon record review and interview the facility failed to follow policy procedures, failed to ensure that comprehensive care plans are reviewed quarterly, failed to ensure that the goal target date is within 90 days, and failed to revise an advance directive care plan (as directed) for one of four residents (R4) reviewed for change in condition.Findings include:R4's ([DATE]) POLST (Practitioner Orders for Life-Sustaining Treatment) Form states No CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation. R4's ([DATE]) POS (Physician Order Sheet) includes Do Not Resuscitate.R4's ([DATE]) care plan states Advance Directive - Full Code however R4's POLST and POS affirm DNR status. R4's Advance Directive care plan was revised on [DATE] (over 3 months ago) with Target Date: [DATE] (roughly 6 months later). On [DATE] at 2:33pm, surveyor inquired about required care plan review and/or revision V6 (Director of Nursing) stated They're quarterly and or if it's a significant change. Surveyor inquired if care…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-24 · tag F0610 — failed to investigate and act on abuse reports — isolated
  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 follow their abuse policy by failing to investigate an allegation of misappropriation of resident's fund by another resident. This failure affected two of three (R4 and R6) residents reviewed for investigating residents' allegations of misappropriation of funds.Findings include:R4 is [AGE] years old admitted to the facility on [DATE], past medical history includes, but not limited to Osteomyelitis, other acute osteomyelitis left ankle and foot, acquired absence of other left toes, iron deficiency anemia, paranoid schizophrenia, moderate protein calorie malnutrition, unspecified open wound left lower leg, prediabetes, delusional disorders, chest pain, etc.On 7/14/2025 at 11:30AM, R4 was observed in her room, alert and oriented and said that she was sent to the hospital because she had an argument with another resident (R6), R4 stated that R6 stole from her, she used R6's phone to order food one time and R6 ended up making numerous charges to R4's credit…

  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 · F2025-06-26 · tag F0908 — failed to keep essential equipment working — widespread
  Keep 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 ensure the chillers (air conditioner units) were in operating condition and functioning properly. These failure have the potential to affect all 202 residents residing at the facility. Findings include: Facility census, dated 6/22/2025, documents 202 residents residing at the facility. On 6/22/2025, resident room temperature checks were performed with V3 (Assistant Administrator). On the first, second, and third floors, three rooms on each floor had adequate temperatures ranging from 76.2 degrees Fahrenheit to 80.0 degrees Fahrenheit. On 6/22/2025, facility halls/hallways temperature checks were performed with V3 (Assistant Administrator) for inadequate cooling and the following concerns were identified: First floor low side hall/hallway: 88 degrees Fahrenheit First floor high side hall/hallway: 85.6 degrees Fahrenheit Third floor low side hall/hallway: 87.2 degrees Fahrenheit Third floor high side hall/hallway: 89.1 degrees Fahrenheit…

  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 · Fcited before2025-06-26 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to keep the facility temperature below 81 degrees Fahrenheit and failed to ensure the temperature was comfortable for one resident (R3) out of 6 residents reviewed for safe, comfortable environment. These failures have the potential to affect all 202 residents residing in the facility. Findings include: Facility census, dated 6/22/2025, documents 202 residents residing at the facility. On 6/22/2025, resident room temperature checks were performed with V3 (Assistant Administrator). On the first, second, and third floors, three rooms on each floor had adequate temperatures ranging from 76.2 degrees Fahrenheit to 80.0 degrees Fahrenheit. On 6/22/2025, facility halls/hallways temperature checks were performed with V3 (Assistant Administrator) for inadequate cooling and the following concerns were identified: First floor low side hall/hallway: 88 degrees Fahrenheit First floor high side hall/hallway: 85.6 degrees Fahrenheit Third floor low side…

  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 · D2025-05-19 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  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 document providing the bed hold policy to the resident or representative upon transfer to a local hospital, for one (R2) of three residents reviewed for bed hold policy. Findings include: R2 is a [AGE] year old male originally admitted on : 8-5-2024 with medical diagnosis that include ans are not limited to: Bipolar disorder and suicidal ideation. On 4-11-2025 R2 was transfer via 911 to a local emergency room with involuntary petition. On 5-18-2025 at 12:50pm V1 said, the bed hold policy should be given with explanation when a resident is sent out to the hospital, my expectation is that the staff will document it in the electronic medical record, we do not have any documentation that indicate that R2 received the bed hold notification. R1 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: Bipolar disorder, diabetes type 2, alcohol dependent and hypertension. R1 was transfer to a local…

  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 · Fcited before2024-11-20 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interview, and record review the facility failed to follow the hand hygiene policy. This failure has a potential to affect all 216 residents currently residing in the facility. Findings include: On 11/17/24 at 11:10 AM, Surveyors were provided the facility census that listed 216 residents currently residing in the facility. On 11/18/24 at 10:34 AM, Surveyor observed, third floor unit, V20 (Certified Nurse Assistant) walking out of a resident's room the third floor unit without performing hand hygiene. Surveyor interviewed V20 (CNA) who said in the summary, there are no hand sanitizers in the hallways or residents' rooms due to residents' cognitive condition, resident use to try to drink hand sanitizer. We are supposed to always have personalized hand sanitizers in our pockets. I don't have a hand sanitizer with me right now. Surveyor further inquired how did V20 (CNA) sanitize hands upon exiting resident's room, V20 (CNA) said, I have no way to sanitize my hands right now. On 11/18/24 at 11:13 AM, surveyor observed V5 (Wound Care Nurse) perform wound care for…

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

  Infection Control 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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$147,914 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $16,575 — penalty dated 2025-07-24
• $22,698 — penalty dated 2025-07-24
• $40,660 — penalty dated 2024-11-20
• $51,180 — penalty dated 2024-08-29
• $16,801 — penalty dated 2024-04-26
• Medicare payment denial — starting 2025-08-23 for 28 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 SABA HEALTHCARE — 11 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 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

About 95% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $5.5M paid to related parties — landlords or management companies under common ownership — equal to about 35% 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.

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