Inverness Rehab

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.

45.0% 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 82 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 57 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 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 142 beds and averages 114.0 residents a day — about 80% occupied, or roughly 28 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 3.00 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.71 hrs/resident/day on weekends vs 3.12 on weekdays — 13% thinner on weekends. RN hours go from 0.53 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

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.

34 citations, most serious first. The 16 most serious are shown; the remaining 18 are one tap away and print in full.

• Actual harm · Gcited before2026-02-06 · 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 follow their change in condition policy by not notifying the provider about a resident's urinary retention and being unable to drain urine through catheterization. This failure has caused 1 of 3 residents (R1) in a sample of 3 reviewed for catheter care to be admitted to the intensive care unit (ICU) for aggressive treatment for sepsis secondary to urinary tract infection (UTI).The findings include:R1 is a [AGE] year-old female originally admitted on [DATE], having a slight cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. A further review of the MDS also documents that R1 was admitted with an admitting diagnosis including urinary retention and Urinary Tract Infection (UTI).A review of the admission progress note dated 12/26/25 documented that R1 was admitted with a Foley catheter in place.A review of the Physician Order Sheet (POS) and Medication Administration Record (MAR) documented a physician order in place dated 1/21/26 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
• Actual harm · Gcited before2024-07-11 · 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 implement effective fall interventions and adequate supervision for a dependent resident assessed as a high risk for falls with diagnoses of Parkinson's disease and Dementia. This failure affected one (R99) of three residents reviewed for falls in the sample of 44. This failure resulted in (R99) experiencing repeated falls that resulted in hospitalizations, sustaining lacerations on two occasions, with one laceration requiring three sutures. Findings include: R99 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's disease, dementia, depression, ataxic gait, cognitive communication deficit, urgency of urination and visual hallucinations. On 07/08/24 at 12:44 PM surveyor observed R99 dining in reclining chair with no concerns. R99 had an approximate quarter size yellowish purple bruise to right outer eye area. On 07/08/24 at 2:59 PM surveyor observed R99 sitting in TV…

  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 · G2023-04-13 · 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 prevent a resident from being verbally abused by a CNA (Certified Nursing Assistant) for one of two residents (R337) reviewed for abuse in the sample of 45. This failure resulted in R337's psychosocial harm as witnessed by R337's increased anxiety and agitation. Findings include: R337 was admitted to the facility on [DATE] with diagnosis including but not limited to Malignant Neoplasm of Endometrium, Polyneuropathy, Osteoarthritis of knee, Essential Hypertension, and Acquired Absence of both Cervix and Uterus. On 04/10/2023 at 01:42 PM Surveyor observed R337 laying the bed, with eyes closed. V16 (R337's husband) sitting at the bedside, indicated R337 is not able to be interviewed at this time. On 04/10/2023 at 1:45 PM V16 (R337's husband) stated, On Thursday, 04/06/2023, one of the staff said to R337, I'm not going to turn you. I don't want to hurt my back. You're going to die anyways. R337 could still talk at that time, and she thought it…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-04-13 · 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 provide necessary care and radiological services in a timely manner, failed to follow the physician order for a STAT/immediate x-ray; failed to follow their diagnostic/labs notification policy and caused a delay in treatment for 1 (R187) of 3 residents reviewed for quality of care from the sample of 45 residents. This failure resulted in R187 waiting over 48 hours to obtain an x-ray that revealed a transverse fracture of the arm causing delayed treatment of the fracture. Findings include: R187 is blind and cognitively impaired resident admitted to the facility on [DATE] for a 5-day hospice/respite stay and with diagnoses of Alzheimer's Disease, atrial fibrillation, obstructive sleep apnea, seizures, anxiety disorder, and cardiac pacemaker. A facility federal report notification dated 2/27/23, authored by V6 (previous Director of Nursing) reads in part (but not limited to): Per staff interview, on 2/22/2023, (CNA/Certified Nurse Assistant) dressed…

  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 before2023-04-13 · 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 observation, interview, and record review, the facility failed to follow the plan of care and procedures for wound care to prevent and heal avoidable facility-acquired pressure ulcers for 2 (R3, R64) of 3 residents reviewed for pressure ulcers in the sample of 45 residents. This failure resulted in R3 and R64 to sustain facility-acquired, clinical stage 4 pressure ulcers that required surgical removal of necrotic tissue. Findings include: On 4/10/23 at 10:00 AM the facility presented survey team with a list of the facility's pressure ulcer list which showed R3 and R64 with facility-acquired stage IV pressure wounds. 1. R3 is cognitively impaired with diagnoses listed in part with hypertension, anxiety state, congestive heart failure, atrial fibrillation, and diabetes. MDS (minimum data set) assessment dated [DATE] showed R3 with no pressure ulcers upon assessment but was considered at-risk for the development of pressure ulcers. This same assessment showed R3's listed skin and ulcer/injury treatments 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
• Actual harm · G2023-04-13 · 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 provide effective pain management for a hospice resident with severe cognitive impairment, failed to identify signs and symptoms of pain for 1 (R187) of 5 residents reviewed for pain in the sample of 45 residents. It can be determined that the reasonable person in the resident's position would have experienced pain from the left forearm fracture. Findings include: R187 was admitted to the facility on [DATE] for a 5-day respite stay under hospice care with diagnoses of Alzheimer's Disease, atrial Fibrillation, obstructive sleep apnea, seizures, anxiety disorder, cardiac pacemaker. Per facility medical records, R187 is blind, cannot communicate her needs and totally dependent on staff. A facility federal report notification dated 2/27/23, authored by V6 (previous Director of Nursing) reads in part (but not limited to): Per staff interview, on 2/22/2023, (CNA/Certified Nurse Assistant) dressed resident and reports skin intact and no skin…

  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 · F2025-08-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, interview and record review, the facility failed to ensure food items in the walk-in refrigerator were labeled or dated. This practice has the potential to affect all 116 residents residing in the facility who receives food from the kitchen. The facility also failed to document personal refrigerator temperature logs and discard expired food from the refrigerators for seven residents R23, R28, R43, R30, R43, R65 and R72 reviewed for refrigerator logs in a sample of 24 residents.During an initial tour of the kitchen on 8/19/25 at 10:00am, surveyor and V17(Food service Director) observed in the walk-in freezer a sandwich condiment tray containing coleslaw salad, egg salad, lettuce, tomatoes, and sliced turkey with a use by date of 8/15/25. During an interview, at 10:15 am, V17 stated that the condiments tray should not be in the refrigerator. Facility policy dated 1/25/2025 title: Date Marking for Food Safety reads, The facility adheres to a date marking system to ensure the safety of ready-…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-22 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure infection control measures are implemented and prescribed oxygen inhalation was administered for 10 of 10 residents (R7, R14, R15, R23, R36, R45, R60, R63, R86, R98) reviewed for oxygen in a sample of 24. Findings include: R7 is a [AGE] year-old female admitted on [DATE] with medical diagnoses that include and are not limited to: diabetes mellitus type 2, chronic kidney disease, heart failure, hypertension, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris and peripheral vascular disease. On 8/19/2025 at 11:30 AM, R7 observed sleeping on the bed with oxygen concentrator @ 2LPM (liters per minute), humidification bottle not labeled, via nasal cannula (NC), oxygen tubing located on the floor with no date or labeling on the tubing. No oxygen sign located on doorway, nowhere visible. Oxygen via nasal cannula was not on R7. On 8/19/2025 at 1:00 PM V2 (Director of nurse), made aware of above 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
• Potential for harm · Ecited before2025-08-22 · tag F0755 — failed to provide safe pharmacy services — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately account for controlled medications for four of four residents (R42, R63, R87, R98) reviewed for controlled medications in a sample of 24. Findings include:1. R98 is a [AGE] year-old male with admission date of 07/09/2025 and diagnoses of not limited to unspecified asthma and obstructive sleep apnea. Review of R98's Order Summary Report dated 08/20/2025 indicated an order for Pregabalin 100mg (milligram) one time a day with order date of 07/09/2025. On 08/20/2025 at 10:25AM during medication administration observation with another surveyor, V11 (Licensed Practical Nurse) removed a pill from R98's Pregabalin 100mg blister pack. At 10:40AM after giving the medications to R98, V11 went back to the cart and did not sign R98's Controlled Drug Receipt Record/Disposition Form of Pregabalin 100mg. 2. On 08/20/2025 at 11:38AM during review of controlled medications with another surveyor and V11, the following were noted:1. R42'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 · Ecited before2025-08-22 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications are stored securely for two of two residents (R80, R122) reviewed for medication storage in a sample of 14. The facility also failed to label multidose medication with open date which has the potential to affect all 24 residents currently residing in Unit 3, and all potential new admissions in Unit 3. Findings include: R122 is a 73- year- old male admitted on [DATE] with medical diagnoses that include and are not limited to: diabetes mellitus type 2, adjustment disorder with depressed mood, hypertension heart disease without heart failure, atrial fibrillation and peripheral vascular disease. On [DATE] at 11:20 AM, observed a medication cup with multiple medications left at bedside in R122's room and no nurse in the room. On [DATE] at 11:00 AM R122 stated he did not know how long those medications have been sitting on the nightstand. R122 stated he had barely gotten out of his bed to sit in his wheelchair one hour ago.…

  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 · E2025-08-22 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement infection control measures during medication administration procedures for four of four residents (R3, R21, R30, R39) reviewed for medication administration in a sample of 24. Findings include:1. R21 is an [AGE] year-old male with admission date of 08/19/2025 and diagnosis of not limited to hyperlipidemia. On 08/20/2025 at 9:36AM during medication administration observation with another surveyor, V10 (Licensed Practical Nurse) disinfected a scissor with disinfectant wipes while wearing gloves then immediately proceeded to cutting the top of R21's Omega-3 fatty acids soft gel capsule without performing hand hygiene and changing gloves. On 08/20/2025 at 9:51AM during interview with V10, V10 stated that she should have performed hand hygiene and changed gloves before she cut R21's Omega-3 fatty acids soft gel capsule. Review of R21's Medication Administration Record for August 2025 indicated that V10 partially administered R21'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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-22 · 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 observation, interview, record review, the facility failed to ensure low air loss mattress device was on the correct weight setting for a resident identified to be high risk in developing pressure ulcers. This deficient practice affects one (R23) of three residents reviewed for pressure injury prevention and treatment in a final sample of 24 residents. Findings Include: R23 is a [AGE] year-old male resident, with diagnoses of but not limited to: paraplegia chronic respiratory flare, heart failure, morbid obesity, anemia, and neurogenic bowel.On 8/19/25 at 11:10AM, observed R23 in bed, awake and alert on low air loss mattress set on 420 lbs. Per R23, he weighs 314 lbs the last time R23 was weighed.On 8/19/25 at 11:40AM, Observed and confirmed with V4 (ADON) that the low air loss mattress is set on 420 lbs. R23 commented that that is the setting R23 is comfortable with.On 8/21/25 at 8/21/25 at 10:30AM, V13 (Wound Nurse) stated that R23 is high risk for skin alteration such as pressure ulcer inuries.…

  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 · D2025-08-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  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 services to maintain the highest level of mobility for one of six residents (R14) reviewed for mobility in a sample of 24. Findings include:R14 is an [AGE] year-old male with admission date of 11/24/2022 and diagnosis of not limited to chronic obstructive pulmonary disease and acquired absence of left leg above knee. During record review, R14 was not on any restorative nursing program. R14's Functional Abilities and Goals dated 06/03/2025 indicated R14 needs partial/moderate assistance with chair/bed-to-chair transfer and toilet transfer, and tub/shower transfer. Review of R14's Rehabilitation Screening Form dated 05/06/2025 indicated R14's current level of assistance with transfer was standby assist (SBA). Review of R14's Physical Therapy Discharge Summary on 01/23/2025 indicated R14's functional skills assessment revealed that R14 was independent with chair/bed-to-chair transfer and toilet transfer. On 08/20/2025 at 11:35AM during interview…

  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 · Dcited before2025-08-22 · 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 implement interventions to reduce accident hazards and risks for one of two resident (R100) reviewed for accidents in a sample of 24. Findings include:R100 is an [AGE] year-old female who was admitted in the facility on 10/17/2024 with diagnoses of not limited to history of falling, anxiety disorder, Alzheimer's disease and unspecified dementia. On 08/19/2025 at 9:51AM during unit rounds, V8 (Hospice Certified Nursing Assistant/CNA) was performing incontinence care and assisting R100 with personal hygiene. V8 called for assistance from facility staff to transfer R100 via mechanical lift in which V9 (CNA) responded. V8 placed the reclined chair on the corner at the foot of the bed with the head part closer to the bed. V9 stood on the left side of the reclined chair which was the farther side from R100. V8 controlled the mechanical lift, and no staff was guiding R110's body midair while being transferred by V8. On 08/19/2025 at 9:55AM…

  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 · Dcited before2025-08-08 · 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 provide medication as ordered by the prescriber to meet the needs of the resident, including acquiring medications. This failure affects one of three residents (R2), reviewed for medication administration.Findings include: On 8/7/2025 at 11:00am R2 said on Sunday 8/3/2025 and she think also Monday 8/4/2025 she did not have her 9am or her 1pm medication, it is for her anxiety and she was not informed until she counted her medication and it was short a pill, she then ask the nurses and they both said the medication had not been delivered, I then informed the social worker I wanted to file a grievance. On 8/7/2025 at 11:40am V3(Social Services Director-SSD) said that R2 ask to file a grievance because the nurse had not administered her medication, I did assist her with the grievance and then I informed the Assistant Director of Nursing-ADON. On 8/7/2025 at 12:00pm V4(Assistant Director of Nursing-ADON) said that V2 had already been informed about the medication not being administered, my expectation is that the nurses will…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-20 · 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 follow their policy to ensure that blood glucose monitoring for three (R1, R3, R4) of three residents reviewed for blood sugar monitoring were checked before meals per the physician order. Findings include: On 6/17/2025 at 3:12 PM, V3 (RN) said that today is V3 first day work with R1. V3 said he first entered R1's room after 11:00 AM. V3 said that he was supposed to check R1's blood pressure and blood sugar. V3 said that the blood pressure and blood sugar was supposed to be done in the morning. V3 said that he had 29 residents, V3 said that he lost tract because the CNA was asking him for help with different residents. V3 said that he also lost internet between 9:30 AM and 10:00 AM check. V3 said that blood sugar checks were supposed to be done before breakfast. V3 said that by the time V3 lost internet connection, the residents had already eaten breakfast. V3 said that R1 refused for her blood sugar and blood pressure to be checked because she already…

  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

$22,679 in federal fines across 1 penalty.

• $22,679 — penalty dated 2024-07-11

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

Who owns this facility

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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 $562K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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