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Avantara Lake Zurich

900 South Rand Road, Lake Zurich, IL 60047 · For profit - Limited Liability company · 203 certified beds · (847) 726-1200 Medicare & Medicaid certified

Call the home — (847) 726-1200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2024Behavioral-health or dementia-care citations — no harm found (F0744, F0758)1 actual-harm citation1 immediate-jeopardy citation CMS recorded as corrected before the inspection ended (past non-compliance)$15,124 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (34) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,124 in federal fines (most recent 2025-05-12)
  • its facility-reported quality-measure score sits well above its independent inspection score

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3880 Salem Lake Dr Ste F · (847) 719-2220 · Call to confirm hours
Pharmacy
41 E Main St Ste 200 · (847) 540-9590 · Call to confirm hours
Grocery
Mariano's0.6 mi
1350 E IL Route 22 · (847) 438-4003 · Call to confirm hours
Park
836 Jewett Park Dr · Typically dawn to dusk
Place of worship
23286 N Quentin Rd · (847) 438-7457

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.5%13.4%15.4%better
Long-stay residents who lose too much weight4.0%6.3%5.4%better
Long-stay residents with a catheter left in their bladder1.6%0.9%0.9%worse
Long-stay residents with a urinary tract infection0.2%1.5%2.0%better
Long-stay residents with depressive symptoms99.3%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.6%3.1%3.3%worse
Long-stay residents whose ability to walk worsened7.6%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication7.8%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine90.4%91.8%95.3%typical
Long-stay residents with pressure ulcers2.1%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control31.0%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table20.4%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.4%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine90.9%63.1%79.4%better
Short-stay residents rehospitalized after admission21.6%26.1%22.6%typical
Short-stay residents with an outpatient ER visit12.5%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.992.021.67worse
Long-stay outpatient ER visits per 1,000 resident days0.552.221.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

59.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 372 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.3%U.S. median 51.5%
Got home and stayed home
10.6%U.S. median 10.7%
Went back to hospital
71.2%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 71.2% 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 212 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 0.26 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF59.3%CMS range 55.0–63.551.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.6%CMS range 7.8–13.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge71.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge73.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting93.5%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge94.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 3.5–8.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.821.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.05
RN hours/ resident / day
0.46
LPN hours/ resident / day
2.02
Aide hours/ resident / day
3.53
Total nurse hours/ resident / day
0.95
RN hoursweekends
36.5%
Total nursing turnover
29.6%
RN turnover

How full it usually is: this home is certified for 203 beds and averages 143.1 residents a day — about 70% occupied, or roughly 60 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.05 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.41 hrs/resident/day on weekends vs 3.58 on weekdays — 5% thinner on weekends. RN hours go from 1.09 to 0.95 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

10
deficiencies at the latest standard inspection (2026-05-06)
5
at the previous standard inspection (2025-01-16)

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.

ABCDEFGHIJKL

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 12 most serious are shown; the remaining 22 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2025-05-12 · 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 ensure the front entrance to the facility was safely supervised and/or secured to prevent 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6 from exiting the facility unbeknown to the staff. This failure resulted in R1 leaving the facility in the early morning hours and crossing four lanes of a major east-west arterial road where the speed limit is 50 miles per hour (MPH) wearing only a hospital gown, a brief, and shoes. R1 became hypothermic and was admitted to the hospital with an acute subdural hematoma, hypothermia due to cold environment, and unwitnessed fall. The Immediate Jeopardy began on 4/13/25 when staff could not find a resident in the facility. V1, Administrator, was notified of the Immediate Jeopardy on 5/12/25 at 4:20 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on 4/16/25, prior to the start 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.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Actual harm · Gcited before2024-03-04 · 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 ensure a resident with a history of falls and right sided weakness was safely transferred. This failure resulted in R1 sustaining a fall, hitting her head on the bedside table, and falling on her left side during a transfer. R1 was sent out to the local hospital and CT showed acute displaced fracture of the right ilium and right acetabulum. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 5. The findings include: R1's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE]. R1's diagnoses include hemiplegia and hemiparesis following cerebral infarct affecting right dominant side, osteoarthritis, low back pain, overactive bladder, unsteadiness on feet, weakness, contusion of scalp, fracture of right pubis, history of falling and presence of left artificial hip joint. R1's undated Admission/Hospital Report documents she is alert and oriented x2, maximum two person assist and right sided weakness. R1'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-05-06 · 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

    Based on observation, interview, and record review the facility failed to ensure dishes were air-dried prior to stacking. This has the potential to effect all residents receiving food from the kitchen. The findings include: Centers for Medicare and Medicaid Services form 671 dated 5/4/26 shows there are 143 residents residing in the facility. Facility Diet Type Report dated 5/4/26 shows only one resident has an order of NPO (nothing by mouth) and does not receive food from the kitchen. On 5/4/26 at 10:55 AM, V11 (Dietary Aide) was on the clean, outfeed side of the dish machine. V11 was removing trays from the dish racks immediately out of the dish machine without allowing it to air dry. V11 would place the trays on an adjacent cart in a manner that allowed them to air dry. When V11 ran out of room, V11 began stacking the trays top to bottom, on top of the row of previously placed trays, while still wet and did not allow them to air dry. V11 also stacked insulated plate tops with the tops facing down, stacking additional insulated plate tops directly on top of the last on the bottom…

    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 · E2026-05-06 · tag F0550 — failed to protect resident dignity and rights — pattern
    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

    Based on observation, interview, and record review, the facility failed to ensure residents were treated in a dignified manner for 4 of 30 residents (R152, R12, R14, and R113) reviewed for dignity in the sample of 30.The findings include: 1. On May 4, 2026, during the lunch meal, V13 and V16 Certified Nursing Assistants (CNA) were feeding residents at one of the tables. V13 and V16 were talking to each other in spanish in front of english-speaking residents. Staff were also observed speaking across the dining room to each other in spanish. The dining room was full of residents eating their lunch meals including R12, R14, and R113. 2. On May 5, 2026, at 12:45 PM, V19 Registered Nurse (RN) was standing next to R152 feeding him the lunch meal. There was an empty chair next to V19. On May 6, 2026, at 9:34 AM, V13 CNA said staff should be sitting when they are feeding the residents so that they are eye level with the residents. V13 said if a resident is spanish speaking, then staff can speak to them in spanish. V13 said english should be spoken in the dining room because this is 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 · Ecited before2026-05-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    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 observations, interviews, and record review, the facility failed to ensure pressure relieving interventions were in place and failed to ensure ordered treatments were in place for five of eight residents (R113, R75, R9, F26, and R31) reviewed for pressure injuries in the sample of 30. The findings include:1. R113's admission Record shows she was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, bipolar disorder, anxiety disorder, dementia, and major depressive disorder. R113's Pressure Injury Risk assessment dated [DATE], shows she is high risk for developing pressure injuries. R113's Skin and Wound note dated April 11, 2026, shows R113 was seen by the wound care nurse practitioner for new wound evaluation. R113 had a deep tissue pressure injury to her left heel that measured 6.5 centimeters (cm) X 5 cm and a deep tissue pressure injury to her right heel that measured 4.5 cm X 4 cm. R113's Order Summary Report dated May 5, 2026, shows orders for Wound Care left and right…

    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 · D2026-05-06 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure a resident and their personal property were respected. This applies to 1 of 30 residents (R76) reviewed for resident rights in the sample of 30. The findings include: R76's face sheet shows she has diagnoses including type 2 diabetes, chronic kidney disease, hypertension, atrial fibrillation, CHF, and acquired absence of right leg below the knee. On 5/5/26 at 9:02 AM, loud yelling was heard in the hallway coming from R76's room. Get out, Get out repeatedly. V23 (Licensed Practical Nurse) was outside of R76's room. He said the housekeeper and V25 (Regional Relations Director) are in her room trying to throw items away from R76's fridge. Food items can only be in the fridge for 72 hours and should be discarded. V25 remained in the room during the escalation. V3 (Guest Relations) entered R76's room. R76 was heard from the hallway agitated. V25 came out of R76's room upset and asked to speak to V23. V23 said V25 reported R76 was physically aggressive with her and needed to be sent out for psych evaluation.…

    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 · D2026-05-06 · 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 provide incontinence care to residents that require staff assistance with toileting. This applies to 2 of 30 residents (R17 and R14) reviewed for activities of daily living in the sample of 30. The findings include: 1. R17's face sheet shows she had diagnoses of type 2 diabetes, hypertension, COPD, asthma, osteoporosis and chronic kidney disease. On 5/4/26 at 11:08 AM, V22 (Registered Nurse) said R17 has redness to her buttock from being saturated. On 5/4/26 at 1:00 PM, R17 was lying in her bed. She said she is soiled and needs to be changed. She was last changed by the overnight staff. She said she has a sore on her bottom and V9 (Wound Nurse) has been putting cream on her bottom. On 5/4/26 at 1:20 PM, V9 (Wound Nurse) said R17 has a history of pressure injury to her bottom. R17 has redness to her bottom, she gets medicated cream to her bottom. R17 is incontinent of bowel and bladder and should be changed frequently. V9 entered R17's room,…

    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 before2026-05-06 · 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 ensure a resident's skin was cleansed after an incontinent episode for one of four residents (R74) reviewed for incontinence in the sample of 30. The findings include:R74's admission Record shows she was admitted to the facility on [DATE] with diagnoses including insomnia, chronic kidney disease, Alzheimer's disease, dementia, and mood disorder. R74's Care Plan initiated on June 6, 2023 shows, Keep skin clean and dry. R74's Minimum Data Set (MDS) dated [DATE] shows she is not cognitively intact. R74 has not exhibited behavior of rejecting care. R74 requires substantial/maximal assistance with toileting hygiene and personal hygiene. R74 is frequently incontinent of urine and always incontinent of bowel.On May 4, 2026 at 11:06 AM, R74 was walking the halls throughout the memory care unit. R74's pants were wet past her knees towards the inside of her legs. V15 Certified Nursing Assistant (CNA) and V13 CNA brought R74 to her room to change…

    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 before2026-05-06 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement person-centered dietary interventions to support independent eating, maintain dignity, and promote adequate nutritional intake for one resident (R112) with a diagnosis of dementia and a preference to eat meals using their hands in the sample of 30.The findings include:R112's Face Sheet printed on 3/6/26 showed R112 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and moderate protein calorie malnutrition.R112's Care Plan printed on 5/6/26 showed R112 has an alteration in neurological status related to dementia with an intervention to accommodate eating issues in order to maximize independence and nutritional intake as well as an alteration in nutritional status related to dementia with an intervention to consider finger foods.On 5/4/26 at 12:45 PM, during the lunch meal, R112's meal was lemonade, broth soup, turkey stuffing casserole, green beans, and spaghetti noodles. R112 was observed attempting to consume non-finger…

    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 before2026-05-06 · 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 observation, interview, and record review the facility failed to ensure residents consumed their medications when medications were administered for 2 of 6 residents (R164 and R33) reviewed for pharmacy services in the sample of 30.The findings include:1. On 05/04/2026 at 10:47 AM, R164 was in her room in bed. A clear plastic medication cup was sitting on the table in R164's room. There were four pills in the cup. No staff were present in R164's room. R164 said she was not sure if the pills were hers.On 05/04/2026 at 10:49 AM, V7 (Registered Nurse- RN) said R164 did not self-administer medications.R164's Care Plan (undated) did not indicate R164 could self-administer medications. 2. On 05/04/2026 at 10:25 AM, R33 was in her room. On the bedside table was a clear plastic medication cup that contained two white ovel pills. No staff were present in R33's room. R33 stated she would take the pills later. On 05/04/2026 at 10:44 AM, V6 (RN) said R33 did not self-administer medications.R33's Care Plan (undated) did not indicate R33 could self-administer medications.On 05/05/2026 at…

    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 before2026-05-06 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 administer medications as ordered (at ordered times and ordered routes). There were 30 opportunities with 6 errors resulting in a 20 % error rate. This applies to 3 of 4 residents (R102, R107, R162) observed in the medication pass.The findings include: 1.On 5/4/26 at 10:45 AM, V22 (Registered Nurse) was observed during morning medication pass. V22 prepared R107's medications including acetaminophen 325 mg (milligrams) two tablets, Colace 100 mg one tablet, spironolactone 25 mg one tablet, apixaban 2.5 mg one tablet and carbidopa-levodopa 25-100 mg one tablet. Six pills were in the medication cup. V22 entered R107's room and gave her the medication cup. R107 stated, I'm missing one, there's only six pills. I usually have 7 pills in the morning. V22 replied, No you have all your medications. V22 went back to her medication cart and did not check R107's EMAR (electronic medication administration record) to verify if R107's medications 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-06 · tag F0880 — failed to prevent and control infections — isolated
    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 ensure staff changed gloves and performed hand hygiene to prevent cross contamination, and failed to ensure staff wore the required personal protective equipment for enhanced barrier precautions for three of 30 residents (R74, R17, and R64) reviewed for infection control in the sample of 30. The findings include: 1.R74's admission Record shows she was admitted to the facility on [DATE], with diagnoses including insomnia, chronic kidney disease, Alzheimer's disease, dementia, and mood disorder. R74's Minimum Data Set (MDS) dated [DATE], shows she is not cognitively intact. R74 has not exhibited behavior of rejecting care. R74 requires substantial/maximal assistance with toileting hygiene and personal hygiene. R74 is frequently incontinent of urine and always incontinent of bowel. On May 4, 2026, at 11:06 AM, R74 was walking the halls throughout the memory care unit. R74's pants were wet past her knees towards the inside of her legs. V15…

    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
Show the remaining 22 citations
  • Potential for harm · D2025-08-26 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was treated in a dignified manner for 1 of 5 residents (R1) reviewed for dignity in the sample of 5. The findings include: On 8/26/25 at 9:54 AM, R1 was in bed in her room. R1 moved slowly as she sat up in bed. R1 said the first night she was here, she had to go to the bathroom and couldn't find her call light. R1 said she uses the bedpan since she has a broken pelvis and is working with therapy on getting up to the bathroom. R1 said no one was coming to check on her and she ended up going in her brief. R1 said she was sitting in urine and yelling for someone to come help her. R1 said she was so frustrated and humiliated, and she called 911 to get help. R1 said while she was on the phone with 911, the nurse came in and asked if she called 911 and what she needed. R1 said she needed to be changed and then staff came to help her. R1 said at first, she was frustrated and humiliated but then it became scary that no one was…

    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 before2025-01-16 · 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

    Based on observation, interview, and record review the facility failed to ensure food was handled in a manner to prevent cross-contamination and failed to ensure a cook performed hand hygiene in a manner to prevent cross contamination. This affects all the residents residing in the facility. The findings include: The facility's CMS Form 671 dated 1/14/25 showed there were 138 residents residing in the facility. On 1/14/25 at 12:35 PM, V6 (Cook) washed his hands, walked with dripping hands to the box of gloves, near the steam table, and applied gloves with wet hands. V6 touched the exterior surfaces of the gloves with his dripping hands numerous times, in an attempt to apply the gloves. V6 went to the walk in-freezer and obtained a large box of frozen vegetable mix, containing several smaller plastic bags of vegetable mix. V6 obtained steel steamer pans from the shelves with the same gloves. V6 opened an individual bag of frozen vegetable mix and placed half of the bag into each steamer pan. V6 used his gloved hands to open the dirty trash can lid (there was food debris noted all…

    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 · Ecited before2025-01-16 · 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 ensure contact/droplet isolation precautions were maintained (R99, R131), failed to ensure enhanced barrier precautions were posted (R113), and failed to ensure personal protective equipment (PPE) was worn in a manner to prevent cross contamination (R131, R52, R32) for 5 of 5 residents reviewed for infection control in the sample of 27. The findings include: 1. R99's face sheet printed on 1/15/25 showed diagnoses including but not limited to influenza virus with respiratory manifestations, elevated white blood cell count, and dementia. R99's order summary report showed an order start dated 1/11/25 for: Maintain at all times: strict droplet isolation precautions due to an active infection. Single room, resident alone and not cohorted with a roommate. Resident remains in the room at all times. All services are done in the room. Every shift for 7 days. On 1/14/25 at 11:42 AM, R99's room had isolation signage, instructions for donning 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure least restrictive interventions were provided prior to the implementation of a physical restraint and failed to release the restraint during supervised activities for 1 of 2 residents reviewed for restraints in the sample of 27. The findings include: On 1/14/25 at 1:05 PM, R90 was sitting in his wheelchair at a table in the dining room. R90 had a lap belt restraint in place and secured closed. At 1:07 PM, R90 was served his lunch and his lap belt restraint remained intact. V21 CNA (Certified Nursing Assistant), V18 CNA, and V19 CNA were in the dining room passing trays and assisting residents. R90's lap belt restraint was not released during the supervised meal. On 1/15/25 at 12:05 PM, R90 was sitting in his wheelchair in front of the nurses's station with his lap belt restraint in place and secured closed. R90 was waiting to leave for an appointment. The surveyor directed R90's attention to his restraint and asked him what it was…

    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 · D2025-01-16 · 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 observation, interview, and record review the facility failed to ensure daily weights were done for a resident with congestive heart failure for 1 of 1 residents (R80) reviewed for weights in the sample of 27. The findings include: R80's face sheet showed she was admitted to the facility 8/21/24 with diagnoses to include Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes, Hyperlipidemia, anxiety disorder, hypertension, and need for assistance with personal care. R80's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires substantial to maximum assistance from staff for most cares. R80's care plan initiated 8/22/24 showed, [R80] has altered cardiovascular status related to hypertension, congestive heart failure,and atrial fibrillation . Vital signs as ordered and PRN (as needed). Notify physician of any abnormal readings . R80's January 2025 Physician Order Sheet showed an order dated 8/21/24 to Monitor weight daily before breakfast. Notify MD of a 2 lb…

    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 before2025-01-16 · 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

    Based on observation, interview, and record review the facility failed to have a dressing in place for the suprapubic catheter and failed to ensure the dressing change to the suprapubic catheter was done as ordered for 1 of 3 residents (R32) reviewed for catheters in the sample of 27. The findings include: On 1/14/25 at 11:06 AM, R32 stated they put medication in his penis this morning because he couldn't pee. R32 stated his catheter was not draining all last night and this morning. R32 stated his groin hurt this morning until the nurse injected something into his catheter and it started draining. R32 stated it feels wet where the urine drains out of his stomach (suprapubic catheter) and he wanted the nurse notified. At 11:15 AM, V17 RN (Registered Nurse) was notified R32 complained that his catheter was leaking. V17 put gloves on and walked into R32's room. V17 went over to R32 and asked him if he felt wet. R32 replied, yes. V17 pulled back R32 covers and pulled down his incontinence brief in front. R32 did not have a dressing over his suprapubic catheter. Urine was draining out…

    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 before2024-10-18 · 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 maintain an indwelling catheter and provide catheter care for residents in a manner to prevent cross contamination for 2 of 3 residents (R1, R2) reviewed for catheters in the sample of 5. The findings include: 1. R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, hypertensive urgency, unsteadiness on feet, neuromuscular dysfunction of bladder, iron deficiency anemia, generalized anxiety disorder, hypertension, chronic congestive heart failure, and generalized osteoarthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment and has an indwelling catheter in place. R1's October 2024 Physician Order sheet showed, . suprapubic catheter: Change dressing around stoma daily . Suprapubic catheter: Record Urine output every shift . R1's care plan initiated 4/3/24 showed, [R1] is at risk for alteration of bowel and bladder functioning related to: indwelling…

    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 before2024-10-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure supervision of a resident while taking medications for 1 of 1 resident (R1) reviewed for medication administration. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes, hypertensive urgency, unsteadiness on feet, neuromuscular dysfunction of bladder, iron deficiency anemia, generalized anxiety disorder, hypertension, chronic congestive heart failure, and generalized osteoarthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment. On 10/18/24 at 10:15 AM, R1 was sitting in her recliner in her room visiting with her niece and a friend. There were several pills scattered on the floor in front of R1's chair and under her bed. R1's breakfast tray was on the bedside table in front of her. R1 said when the nurse brought her medications in earlier she did not have any water to take them so she waited until her breakfast tray was…

    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 before2024-10-04 · 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 ensure accurate assessments were completed for a resident at risk for elopement, failed to ensure quarterly elopement risk assessments were completed, failed to ensure a resident at risk for elopement did not leave the facility unsupervised, failed to ensure exit doors were completely shut with alarm activated, and failed to maintain elopement risk signs and book to ensure they were complete and accurate for 2 of 3 residents (R1 and R2) reviewed for elopement in the sample of 19. The findings include: 1. R1's face sheet. showed he was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm of prostate, hypertension, malignant neoplasm of kidney, hypercalcemia, emphysema, cognitive communication deficit and mile protein-calorie malnutrition. R1's facility assessment dated [DATE] showed he had severe cognitive impairment and was independently ambulatory. R1's 8/27/24 admission Assessment showed, . Elopement Risk…

    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 · D2024-06-11 · 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 interview and record review the facility failed to ensure a resident was free from resident to resident physical abuse. This applies to 2 of 6 residents (R3, R6) reviewed for abuse in the sample of 6. The findings include: R3's Face Sheet dated 6/11/24 shows R3 has the following diagnoses: Alzheimer's disease, dementia with moderate agitation, mood disorder due to known physiological condition with mixed features, delusional disorders, major depressive disorder, and anxiety disorder among other conditions. R3's Minimum Data Set (MDS) assessment dated [DATE] shows R3 experienced physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) four to six days, but less than daily, for the seven day look-back period for this assessment. R3's 5/9/24 MDS assessment also shows R3 experienced verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) daily for the seven day look-back…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-21 · 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

    Based on observation, interview and record review the facility failed to ensure opened, multi-dose vials of medication were labeled with expiration dates for 4 of 7 residents (R2, R5, R10, R6) reviewed for medication storage in the sample of 11. The findings include: 1. R2's physician order dated 2/16/24 showed an order for R2 to receive 15 units (uts) of Insulin Aspart, subcutaneously (SQ), three times a day, prior to meals. On 2/21/24 at 8:15 AM, V7 Licensed Practical Nurse (LPN) withdrew 15 uts of insulin out of an opened vial of Insulin Aspart labeled with R2's name. At 8:32 AM, V7 administered the insulin to R2. At 8:35 AM, R2's insulin vial was reviewed by this surveyor and V7. No opened date or expiration date was noted on the vial. V7 stated all opened medication vials need to be dated when opened and with the date the medication expires to ensure residents aren't receiving expired medications. V7 stated she was not aware that R2's insulin vial had not been dated prior to administering the insulin to R2. V7 stated she should have checked for the expiration date on the vial…

    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 before2024-02-21 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the failed to ensure resident medications were administered according to professional standards and to meet the needs of the residents for 2 of 4 residents (R1, R4) reviewed for medication administration in the sample of 11. The findings include: 1. R1's admission Record showed R1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. R1's February 2024 Medication Administration Record (MAR) showed a physician order (dated 2/8/24) for R1 to receive Humalog Mix 75/25 Insulin, 15 uts (units) subcutaneously, twice a day at 9:00 AM and 9:00 PM. The MAR showed R1 did not receive her prescribed doses of insulin at 9:00 PM on 2/8/24, 9:00 AM on 2/9/24, or 9:00 PM on 2/9/24. On 2/21/24 at 10:32 AM, V6 Registered Nurse (RN) stated she admitted R1 to the facility on 2/8/24. V6 stated R1 did not get her 9:00 PM dose of Humalog 75/25 (insulin) because it had not been delivered from the pharmacy. On 2/21/24 at 10:35 AM, V5 Licensed Practical…

    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 before2024-02-21 · 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 ensure a significant medication error did not occur for a newly admitted resident. This failure applies to 1 of 4 residents (R1) reviewed for medication administration in the sample of 11. The findings include: R1's admission Record showed R1 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. R1's February 2024 Medication Administration Record (MAR) showed a physician order (dated 2/8/24) for R1 to receive Humalog Mix 75/25 Insulin, 15 uts (units) subcutaneously, twice a day at 9:00 AM and 9:00 PM. The MAR showed R1 did not receive her prescribed doses of insulin at 9:00 PM on 2/8/24, 9:00 AM on 2/9/24, or 9:00 PM on 2/9/24. On 2/21/24 at 10:32 AM, V6 Registered Nurse (RN) stated she admitted R1 to the facility on 2/8/24. V6 stated R1 did not get her 9:00 PM dose of Humalog 75/25 (insulin) because it had not been delivered from the pharmacy. On 2/21/24 at 10:35 AM, V5 Licensed Practical Nurse (LPN) stated he cared 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-07 · 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

    Based on observation, interview and record review the facility failed to ensure a resident's prescribed treatment order was changed daily for a resident who has stage 4 left ischial pressure ulcer. This applies to 1 of 3 residents (R5) reviewed for pressure ulcers in the sample of 28. The findings include: 1. R5's Wound Physician Progress note dated 1/10/24 documents stage 4 left ischial pressure ulcer measuring 4 cm (centimeters) x 3 cm x 3.5 cm. Treatment orders include silver alginate daily and cover with foam dressing. R5's Physician Orders Summary (P.O.S.) dated February 2024 shows he has diagnoses including spina bifidia, paraplegia, neuromuscular dysfunction of the bladder and pressure ulcer of sacral region stage 4. The P.O.S. shows orders including wound care left ischial clean with normal saline, pat dry, apply calcium alginate with silver and cover with foam dressing every Monday, Wednesday, Friday (order date 1/10/24). On 2/5/24 at 9:53 AM, V5 (Wound Nurse) was providing wound care to R5. This surveyor asked to observe R5's wound care. V5 said R5 said he does not want 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 · Dcited before2024-02-07 · 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 observation, interview, and record review the facility failed to ensure fall interventions were in place for 1 of 28 residents (R19) reviewed for safety in the sample of 28. The findings include: R19's admission Record showed R19 had the diagnosis of dementia and a history of falls. R19's Fall Risk Evaluation dated 12/17/23 showed R19 was at risk for falls. R19's Progress Note dated 12/17/23 showed R19 had a fall in the bathroom. R19's fall Care Plan showed R19 was to have a bed and chair alarm. R19's Order summary Report showed R19 was to have a bed and chair alarm. On 2/6/24 at 12:00 PM, R19 was in bed. There was no bed alarm on the bed. R19 self transferred from the bed into a wheelchair. No alarm activated when R19 self transferred from the bed to the wheelchair. There was no chair alarm on the wheelchair R19 self transferred too. R19 propelled herself into the bathroom and self transferred to the toilet. No alarm activated when R19 self transferred from the wheelchair to the toilet. A facility assessment done on 9/5/23 showed R19 required extensive assistance 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
  • Potential for harm · Dcited before2024-02-07 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 monitor the behavior of wandering into other residents' rooms for dementia residents for 2 of 8 residents (R19 and R84) reviewed for dementia care in the sample of 28. The findings include: 1. R19's admission Record showed R19 was diagnosed with vascular dementia. On 2/6/24 at 9:31 AM, R19 was self propelling herself in her wheelchair. R19 stopped at the closed door of R112's room and opened the door. R19 went to enter R112's room. R112 stopped R19 from entering and said, Get the f* out of here. R112 said R19 always tries to come into her room. R19 proceeded to go to another resident's room and self transferred into the resident's bed. No staff attempted to redirect R19 from entering other residents' rooms. On 2/6/24 at 12:00 PM, R19 was in another resident's room laying in bed. R19 self-transferred herself into a wheelchair. R19 then propelled herself into the bathroom and used the toilet. After going to the bathroom R19 transferred back into the wheelchair and propelled herself out of the room. No staff…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-07 · 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 observation, interview and record review the facility failed to ensure medications were not left unattended at resident's bedside. This applies to 1 of 28 residents (R2) reviewed for pharmacy services in the sample of 28. The findings include: On February 5, 2024 at 10:39 AM, R2 was sitting in her wheelchair in her room. Her bedside table was sitting in front of her. There was a small blue pill on a book on her bedside table. She stated, she didn't even see that pill there and took the pill. The nurse trusts her to take her medication. The nurse will give R2 the medications and then leave. She doesn't wait to see if R2 takes the medications. R2 also stated, she had dropped her pills in her lap that morning and found one on the floor but didn't see that one (on the book). On February 5, 2024 at 2:14 PM, V3 Registered Nurse (RN) stated, she gave R2 her medications that morning and watched her take them. Maybe it was from yesterday? I know she drops her pills. R2's electronic medical record does not show any self administering assessments. R2's care plan does not show she is…

    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 · D2024-02-07 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review the facility failed to ensure an anti-viral medication was discontinued. This applies to 1 of 5 residents (R25) reviewed for unnecessary medications in the sample of 28. The findings include: R25's current order summary report shows, Tamiflu (anti-viral) oral capsule 75 mg, give 1 capsule by mouth two times a day for flu. The medication was ordered on January 24, 2024 and had no stop date. On February 7, 2024 at 10:25 AM, V7 Assistant Director of Nursing (ADON) stated, the nurse practitioner put the order in the computer and did not put in a stop date. It should have been discontinued after 5 days. R25's medication administration records for January and February shows, she has been receiving Tamiflu (anti-viral) since January 24, 2024 and received an extra 16 doses for 8 days.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure PRN (when needed) anti-anxiety medications had a stop date. This applies to 2 of 5 residents (R25 & R26) reviewed for unnecessary medications in the sample 28. The findings include: 1. R25's current order summary report shows, lorazepam Injection Solution 2 MG/ML (anti-anxiety), inject 2 milligram intramuscularly (IM) as needed for active seizures 2 mg IM,at the onset of seizures MAY Repeat x 1 after 15 minutes if not resolved. The medication was ordered on January 18, 2024 with no end date. The order shows indefinite for end/stop date. 2. R26's current order summary report shows, lorazepam oral tablet 0.5 milligram (anti-anxiety), give 0.25 mg by mouth every 8 hours as needed for anxiety. The medication was ordered on January 28, 2024 with no end/stop date. On February 7, 2024 at 11:22 AM, V2 Director of Nursing (DON) stated, the facility's policy is to have PRN anti-anxiety medications ordered no longer than 14 days. The facility's psychotropic medications dated July 24, 2023 shows, Policy: It is the facility'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 before2024-02-07 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to administer medications at ordered times. There were 28 opportunities with 12 errors resulting in a 42.86% error rate. This applies to 3 of 3 residents (R28, R33, R54) observed in the medication pass. The findings include: 1. On 2/5/24 at 11:15 AM, R28 was self propelling in her wheelchair, looking for the nurse. R28 said she's waiting for her 9:00 AM medications. At 11:22 AM, V4 (RN-Agency) said to R28, I'm finishing up with another resident and when I'm done I'll be over soon. R28 said they are always late with my medications, one day I received my morning medications at 3:00 PM. On 2/5/24 at 11:37 AM, V4 was observed during medication pass. She prepared R5's medications including: Amlodipine 10 mg (milligrams), Metoprolol Extended Release 50 mg, Apixaban 5 mg, Ferrous Sulfate 325 mg, Ascorbic Acid tablet and Miralax. V4 confirmed there was 5 tablets in the medication cup. R28's Medication Administration Record for February 2024 shows orders including to administer at 9:00 AM: 1. Apixaban 5 mg one tablet every…

    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 before2024-02-07 · 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 observation, interview and record review the facility failed to ensure residents were free from significant medication error. This applies to 2 of 3 residents (R28, R33) reviewed for medication administration in the sample of 28. The findings include: 1. On 2/5/24 at 11:15 AM, R28 was self propelling in her wheelchair, looking for the nurse. R28 said she's waiting for her 9:00 AM medications. At 11:22 AM, V4 (RN-Agency) said to R28, I'm finishing up with another resident and when I'm done I'll be over soon. R28 said they are always late with my medications, one day I received my morning medications at 3:00 PM. On 2/5/24 at 11:37 AM, V4 was observed during medication pass. She prepared R5's medications including Apixaban 5 mg twice a day. R28's Medication Administration Record for February 2024 shows orders including to administer at 9:00 AM. Apixaban 5 mg one tablet every 12 hours for pulmonary embolism. 2. On 2/5/24 at 12:09 PM, V4 prepared R33's morning medications. V4 administered coreg 3.125 mg and axiaban 2.5 mg. R33's Medication Administration Record (M.A.R.) 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-07 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 all residents were offered and/or received the recommended pneumococcal immunizations for 1 of 5 residents (R40) reviewed for immunizations in the sample of 28. The findings include: R40's admission Record dated 2/6/24 shows he was admitted to the facility on [DATE] and is [AGE] years of age. R40's Immunization Audit Report dated 2/6/24 shows he last received a Pneumococcal Conjugated Vaccine (PCV13) on 10/15/2015 and a Pneumococcal Polysaccharide Vaccine (PPSV23) on 10/19/2012. Per current Centers for Disease (CDC) guidelines, R40 was eligible for and recommended shared clinical decision-making to decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. On 2/6/24 at 12:34 PM, V7, Assistant Director of Nursing/Infection Prevention (IP) Nurse, said the IP reviews the resident immunizations on admission and annually. If there is a vaccine they are not up to date with, they offer the vaccine, 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.

    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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$15,124 in federal fines across 1 penalty.

  • $15,124 — penalty dated 2025-05-12

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 LEGACY HEALTHCARE — 89 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 →

RatingThis homeChain avg
Overall 4 of 52.9+1.1 vs chain
Health inspection 3 of 52.8+0.2 vs chain
Staffing 3 of 52.5+0.5 vs chain
Quality measures 5 of 53.3+1.7 vs chain
The other 88 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Avantara ArrowheadRapid City, SD 1 of 5Avantara Evergreen ParkEvergreen Park, IL 1 of 5Avantara MilbankMilbank, SD 1 of 5Avantara Saint CloudRapid City, SD 1 of 5Avantara WatertownWatertown, SD 1 of 5Emmetsburg Care CenterEmmetsburg, IA 1 of 5Grove Of Elmhurst, TheElmhurst, IL 1 of 5Harmony Cedar RapidsCedar Rapids, IA 1 of 5Harmony House Health Care CenterWaterloo, IA 1 of 5Harmony MarshalltownMarshalltown, IA 1 of 5Harmony WaterlooWaterloo, IA 1 of 5Harmony West Des MoinesWest Des Moines, IA 1 of 5Nexus at BerwynBerwyn, IL 1 of 5Northgate Care CenterWaukon, IA 1 of 5Park View Rehabilitation CenterSac City, IA 1 of 5Southfield Wellness CommunityWebster City, IA 1 of 5Warren Barr South LoopChicago, IL 2 of 5Avantara GrotonGroton, SD 2 of 5Avantara HuronHuron, SD 2 of 5Avantara Lincoln ParkChicago, IL 2 of 5Avantara Mountain ViewRapid City, SD 2 of 5Avantara Palos HeightsPalos Heights, IL 2 of 5Avantara PierrePierre, SD 2 of 5Avantara RedfieldRedfield, SD 2 of 5Bella Terra BloomingdaleBloomingdale, IL 2 of 5Bella Terra Morton GroveMorton Grove, IL 2 of 5Carlton At The Lake, TheChicago, IL 2 of 5Chalet Living & RehabChicago, IL 2 of 5Colonial Manor of ElmaElma, IA 2 of 5Hallmark Care CenterMount Vernon, IA 2 of 5Harmony DavenportDavenport, IA 2 of 5Harmony DubuqueDubuque, IA 2 of 5Harmony PalosPalos Heights, IL 2 of 5Harmony Utica RidgeDavenport, IA 2 of 5Heritage Care And Rehabilitation CenterMason City, IA 2 of 5Manor House Care CenterSigourney, IA 2 of 5Peterson Park Health Care CtrChicago, IL 3 of 5Avantara LibertyvilleLibertyville, IL 3 of 5Avantara NorthRapid City, SD 3 of 5Bloomfield Care CenterBloomfield, IA

Showing 40 of 88; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
DOROS GENERATION TRUST U/A/D 1/3/12Organization5% OR GREATER DIRECT OWNERSHIP INTEREST17%since 06/01/2021
GPN FAMILY TRUST U/A/D 4/28/08Organization5% OR GREATER DIRECT OWNERSHIP INTEREST17%since 06/01/2021
GARDEN, DANIELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST8%since 06/01/2021
NINIO, MORDECHAYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST59%since 06/01/2021
DULACA, SUSANIndividualW-2 MANAGING EMPLOYEEsince 06/01/2021
TBDMD IL, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2021

3 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.

$17.1M
Net patient revenuemost recent cost report
+5.4%
Operating marginrevenue minus expenses
$284K
Related-party expense2% of expenses
Who pays — share of resident-days
Medicaid 31%Medicare 10%Other / private 59%

This home reported $284K 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

$328per resident / day
operating cost
$9,974per month
≈ monthly operating cost
$347per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145816. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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