Serenity Estates Of Lincolnshire
150 Jamestown Lane, Lincolnshire, IL 60069 · For profit - Limited Liability company · 144 certified beds · (224) 543-7100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (62) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $370,046 in federal fines (most recent 2026-06-23)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (99%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.4% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 12.9% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.3% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 74.5% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.0% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.9% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.9% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.8% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.1% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 31.2% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 56.9% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.7% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.31 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.71 | 2.22 | 1.80 | typical |
‡ 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.
46.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 148 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 28.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 56 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 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.0%CMS range 37.9–53.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.6–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 28.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 21.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 32.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.4% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 6.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.5%CMS range 5.0–13.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 144 beds and averages 117.5 residents a day — about 82% occupied, or roughly 26 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 2.97 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.65 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.69 hrs/resident/day on weekends vs 3.08 on weekdays — 13% thinner on weekends. RN hours go from 0.48 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 99% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
62 citations, most serious first. The 21 most serious are shown; the remaining 41 are one tap away and print in full.
- Immediate jeopardy · Jcited before2026-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident with a known history of elopement while at home did not elope from the facility for 1 of 3 residents (R1). This failure resulted in R1 exiting a secured unit and the facility unsupervised, walking approximately 1,000 feet and crossing a four-lane road in the dark until found by staff approximately 45 minutes later. The Immediate Jeopardy began on 4/19/26 at approximately 3:30 AM, when R1 exited from a secured unit, walked to a different unattended unit and past a nurse's station, down a hallway, and exited the facility unsupervised through a fire exit door. R1 then walked through the rear courtyard for approximately 350 feet, through the facility parking lot another approximate 200 feet, across a four-lane street in the dark, and was found by facility staff around 4:15 AM walking in a nearby shopping center parking lot approximately 1000 feet from where R1 exited the building. V1 (Administrator) 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.
- Immediate jeopardy · Jcited before2026-02-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident with cognitive impairment did not elope the facility and failed to ensure all residents were accounted for one of three residents (R1) reviewed for safety/supervision in the sample of seven.The Immediate Jeopardy began on February 4, 2026, at 5:43 AM when R1 was found sitting outside in the cold in her wheelchair by herself, a block away from the facility and was transferred to the local hospital for cold exposure. V1 Administrator was notified of the Immediate Jeopardy on February 9, 2026, at 3:45 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on February 10, 2026, at 10:34 AM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings include:R1's admission Record shows she was admitted to the facility on [DATE], with diagnoses including left femur fracture, urinary tract infection,…
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.
- Actual harm · Gcited before2026-06-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure daily weight was performed as ordered for a resident with congestive heart failure (CHF). This failure resulted in R1's worsening heart failure condition causing fluid retention and shortness of breath requiring hospitalization for 1 of 3 residents (R1) reviewed for care and services in the sample of 3.The findings include:R1's electronic face sheet shows R1 was admitted to the facility with diagnosis that includes congestive heart failure.R1's Physician Order Sheet dated 5/20/26 show, monitor weight daily before breakfast. Notify MD of a 2 pounds (lbs.) weight gain in one day or 5 lbs. weight gain in one week.R1's Physician Order Sheet dated 5/20/26 shows, R1 was also on diuretics related to acute and chronic congestive heart failure. Spironolactone Oral Tablet 25 milligrams (mg) Give 1 tablet by mouth one time a day. Bumetanide Tablet 2 mg, Give 1 tablet by mouth two times a day. Furosemide Tablet 20 mg, Give 1 tablet by mouth one time a day.…
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.
- Actual harm · Gcited before2026-05-13 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
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 significant medication errors for 1 of 4 residents (R1) reviewed for medications in the sample of 7. This failure resulted in R2 receiving a double dose of an antipsychotic medication for 33 days.The findings include:On 5/12/26 at 1:10 PM, V21 (R2's daughter) said she was visiting R2 one evening around 7:00 PM and the nurse on duty was giving R2 his evening medications. V21 said she inquired about the medications being given and found out that R2 was receiving 200mg of quetiapine fumarate instead of 100mg. V21 said she asked the nurse who authorized the change to 200 mg at night and the nurse did not know. V21 said she went to V2's Director of Nursing office and asked why her dad's medication dose was changed. V21 said V2 told her she had no idea and looked in the computer. V21 said V2 told her that he must have come from the previous facility on that dose. V21 said that there was no way he was on that dose at that…
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.
- Actual harm · Gcited before2026-01-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide necessary care, services, and translation services after a resident experienced a fall and subsequent hip and arm fractures. This failure resulted in R1 experiencing pain and a delay in treatment. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 5. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 5/13/25 with diagnoses to include but not limited to dementia, pubic fracture (onset date 6/27/25), osteoarthritis (joint cartilage breakdown), right shoulder bone density disorder, and spinal stenosis. R1's 11/19/25 Quarterly Minimum Data Set (MDS) showed Mandarin was her preferred language and she would like an interpreter to communicate with a doctor or health care staff. The MDS showed she was not able to complete a Brief Interview for Mental Status (BIMS) test and she had both short and long-term memory problems. The MDS showed she had no range of motion…
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.
- Actual harm · Gcited before2025-04-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident who is a high risk for falls was supervised and failed to ensure fall interventions were individualized for a resident with poor safety awareness and cognitive deficits and failed to ensure bed rails were installed in manner to prevent entrapment. This failure resulted in R1 being found in her room kneeling on the floor with her right arm trapped between the side rail and the mattress sustaining a right comminuted humerus fracture. This applies to 1 of 3 resident (R1) reviewed for safety in the sample of 9. The findings include: R1's Final Incident Report dated 4/15/25 shows on 4/10/25 (R1) is a [AGE] year-old female with diagnoses including atrial fibrillation, type 2 diabetes, major depressive disorder, insomnia, hypertension, and dementia with agitation .(R1) usually transfers with partial to moderate one staff assist and can use call to alert staff when assistance is needed. (R1's) call light was activated, and 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.
- Actual harm · G2025-02-11 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a residents pain was managed for 1 of 4 residents (R1) reviewed for pain in the sample of 4. This failure resulted in R1 experiencing severe pain. Findings include: On 2/11/25 at 10:15 AM, R1 was walking in the hallway of the facility. R1 said she was looking for her nurse. R1 said she has problems getting her medicine especially her Norco (Narcotic Pain Reliever). R1 said she had stomach cancer and had part of her stomach removed. R1 said she has severe stomach pain and Norco is the only way she can eat solid foods without pain. R1 said the facility runs out of Norco all the time and there is always different excuses like the forgot to renew it, the medicine is not delivered yet, or a new doctor took over so they don't have it yet. R1 said they try to give her Tylenol which doesn't help the pain. R1 said she has been taking Norco for years. R1 stated I can take the Norco every 8 hours. It allows me to eat solid food. I have pain…
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.
- Actual harm · Gcited before2024-12-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident was assisted and supervised while ambulating to her room for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 6 residents. This failure resulted in R3 falling and sustaining subarachnoid and subdural hemorrhages. The findings include: On 12/2/24 at 10:16 AM, V14, Director of Nursing (DON) at the time of R3's fall, said V12, Licensed Practical Nurse (LPN), and V13, Nursing Supervisor, called her (on 11/14/24) and said R3 was found on the floor. V14 said V12 and V13 told her R3 was last seen walking toward her room after dinner. V14 said R3's fall was not witnessed, but the nurses had seen R3's drawers were still open, so they assumed she was trying to get something out of them and lost her balance and fell. On 12/2/24 at 11:10 AM, V11, LPN, said she came in to work at 11:00 PM on the night R3 fell. V11 said R3 was already gone to the hospital at that time. V11 said she called the hospital to follow up and see…
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.
- Actual harm · Gcited before2024-09-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify and assess a resident experiencing a change in condition. This failure resulted in a delay in treatment for R1, and R1 experiencing pain due to fractured hip for 1 of 3 residents (R1) reviewed for falls in the sample of 9. Findings include: R1's admission Record, printed by the facility on 9/6/24, showed he had diagnoses including Alzheimer's disease, anxiety disorder, depression, osteoarthritis of knee, restlessness and agitation, weakness, and a history of falling. R1's facility assessment dated [DATE] showed he had wandering behaviors daily. The assessment showed R1 required supervision or touching assistance for walking 50 feet with two turns, and partial/moderate assistance for walking 150 feet. The assessment showed R1 was frequently incontinent of urine, and occasionally incontinent of bowel. The assessment showed R1 was unable to answer when asked if he had pain or hurting at any time in the last 5 days of the assessment. 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.
- Actual harm · G2024-07-10 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse. This failure resulted in R1 being struck in the face by R2. R1 was sent to the local hospital and sustained a closed fracture of the left zygomatic arch (cheek bone). This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include: The facility's Initial Report dated 7/6/24 documents Activity staff reported to the nurse two residents (R1, R2) had an altercation. R1's face sheet shows she is a [AGE] year-old female with diagnoses including zygomatic fracture left side, osteoarthritis, type 2 diabetes, heart failure, cerebrovascular disease, major depressive disorder, unspecified dementia. On 7/10/24 at 9:43 AM, R1 was observed lying in bed, she had a dark purple bruise under her left eye and greenish discoloration to her left cheekbone. The left side of her face had some mild swelling. R1 was alert to herself, she could recall her date of birth and said she…
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.
- Actual harm · Gcited before2024-01-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to supervise a cognitively impaired resident (R65), with a history of falls, in a dining room of the facility. This failure resulted in R65 sustaining an unwitnessed fall requiring R65 to be emergently transported to a local hospital where she was diagnosed with two brain bleeds as result of the fall. This failure applies to 1 of 17 residents (R65) reviewed for safety and supervision in the sample of 17. The findings include: R65's current care plan showed R65 was cognitively impaired related to her diagnosis of dementia. The plan showed R65 was at high risk for falls related to her history of previous falls and impaired cognition. The plan showed R65 exhibited poor safety awareness as evidenced by overestimating or forgetting her limits and forgetting to use her walker when ambulating. R65 required the assistance of one staff, a gait belt, and a walker when ambulating. R65 required staff assistance with toileting and bed mobility. She required staff supervision with transfers and attempting to stand. The facility's Fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-13 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 notify a resident's family of a room change for 1 of 4 residents (R1) reviewed for notification in the sample of 7.The findings include:On 5/12/26 at 1:01 PM, V21 (R1's daughter) said she came in on a Sunday and R2 had been moved into a different room (room [ROOM NUMBER]-B). V21 said the nurse told her R2 had an argument with his roommate Friday night and they moved him to the new room. V21 said she had gone to R2's old room (room [ROOM NUMBER]-B) and R2's personal items were still in that room. V21 said she was upset that no one had called her and they hadn't even moved all of R2's things to the new room, she had to do it. R2's Census List dated 5/13/26 shows on 4/10/26, R2 moved into room [ROOM NUMBER]-B.R2's Progress Notes do not contain documentation on or before 4/10/26 that V21 was notified or the reason for the room change.On 5/13/26 at 10:00 AM, V16 Social Service Director said R2 was moved to room [ROOM NUMBER]-B because of an issue with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-13 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 thoroughly investigate an allegation of abuse for 1 of 7 residents (R3) reviewed for abuse in the sample of 7. The findings include: On 5/11/26 at 1:40 PM, R3 was sitting on the bench seat of her rolling walker in the hall outside of her room. R3 said about a week ago on a Friday she was in the dining area before breakfast with a cup in her hand. R3 said V7 Certified Nursing Assistant took the cup out of her hand and accidently scratched the top of her hand with his fingernail. R3 said it was bleeding and she was upset. R3 said V8 Registered Nurse took care of the cut and put a band aid on it. R3 showed this surveyor the top of her right hand which had a band-aid still in place. R3 said it was healed and removed the band aid. R3's right hand had a healed skin tear in the shape of a half circle approximately the size of a half of quarter. On 5/11/26 at 3:08 PM, V7 said he had come in early for his 7:00 AM shift and was preparing the breakfast trays in the dining room. V7 said R3 was heading out of the unit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to conduct a post fall analysis to ensure fall interventions were appropriate for a resident's self-reported fall for 1 of 3 residents (R1) reviewed for safety in the sample of 7.The findings include: On 5/12/26 at 1:10 PM, V21 (R1's daughter) said she came in to visit her dad, and he told her he had fallen and his back hurt. V21 said she lifted her dad's shirt, and he had a bruise on the left lower side of his back and a scrape on his left elbow. V21 said she went to the nurse on duty V17 Licensed Practical Nurse and asked her why no one called her about her dad falling. V21 said V17 had no idea that her dad fell and then asked R2 why he didn't tell her he fell. V21 said V17 told her she would get someone to send R2 to the emergency room, but V21 declined. V21 said approximately 10 minutes or so later, R2's dinner tray arrived and R2 began eating. V21 said V17 came and wanted to do an assessment on R2. V21 said she told V17 to wait until after R2 finished eating. V21 said V17 never came back to assess R2 so she went to talk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-13 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 be administered in a manner to ensure supplies were available for dependent residents for 1 of 3 residents (R2) reviewed for administration in the sample of 7. The findings include: On 5/11/26 at 1:15 PM, R2 was in bed dressed in a t-shirt and an incontinence brief. R2 said the facility has no briefs and has been out for a couple days. R2 said he wears the green XL size which is the most comfortable for him. R2 said he had a few in his closet but has been wearing them wet to make them last longer. R2 said they are uncomfortable to wear wet, but he has to make them last. R2 said they told him they were waiting on a delivery. R2's closet did not contain any incontinence briefs. On 5/11/26 at 1:35 PM, V5 Certified Nursing Assistant (CNA) said they are out of the green incontinence (XL) brief. V5 said he worked the weekend and they were out then as well. V5 said they have a few pull up briefs but not the ones R2 uses. V5 showed this surveyor the unit supply closet which contained a few pull up incontinence briefs,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-29 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to adequately schedule staff to ensure all units were attended during the overnight shift. This has the potential to effect all 128 residents residing in the facility during the overnight shift. The findings include: Facility Data Sheet shows there are 128 residents residing in the facility as of 4/27/26. Facility provided nursing schedule from 2/27/26 to 4/27/26 shows the facility staffs the overnight shift with three nurses and six certified nursing assistants (CNAs) to cover seven units. Facility nursing schedule from 4/18/26 shows the 700 unit had a census of 23, the 100 unit had a census of 11, and the 200 unit had census of 16. V3 (Licensed Practical Nurse- LPN) was scheduled to cover the 700 unit, the 100 unit, and half of the 200 unit totaling 42 residents. This is a nurse to resident ratio of one to 42.Facility nursing schedule from 4/18/26 shows the 300 unit had a census of 20, the 400 unit had a census of 13, and the 200 unit had census of 16. V10 (Registered Nurse- RN) was scheduled to cover the 300 unit, the 400…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff reported an allegation of verbal abuse to the abuse coordinator for 1 of 3 residents (R1) reviewed for abuse in the sample of 6. The findings include:R1's admission Record showed she was admitted to the facility on [DATE] with diagnoses including, but not limited to chronic kidney disease stage 3, unsteadiness on feet, abnormal posture, abnormalities of gait and mobility, depression, insomnia, anxiety disorder, cognitive communication deficit, primary generalized osteoarthritis, morbid (severe) obesity, type II diabetes mellitus, anemia, and chronic peripheral venous insufficiency. R1's facility assessment dated [DATE] showed she was cognitively intact. The assessment showed R1 had no range of motion impairment to her bilateral upper and lower extremities and used a walker and wheelchair for mobility. Set up/clean up assist for meals. The assessment showed R1 required substantial/maximal assist for toilet hygiene, bathing,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-24 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to suspend a staff member accused of abuse when an allegation was reported for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 6. The findings include:1. R1's admission Record showed she was admitted to the facility on [DATE] with diagnoses including, but not limited to chronic kidney disease stage 3, unsteadiness on feet, abnormal posture, abnormalities of gait and mobility, depression, insomnia, anxiety disorder, cognitive communication deficit, primary generalized osteoarthritis, morbid (severe) obesity, type II diabetes mellitus, anemia, and chronic peripheral venous insufficiency. R1's facility assessment dated [DATE] showed she was cognitively intact. The assessment showed R1 had no range of motion impairment to her bilateral upper and lower extremities and used a walker and wheelchair for mobility. Set up/clean up assist for meals. The assessment showed R1 required substantial/maximal assist for toilet hygiene, bathing,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-11 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to administer medications as order for 3 of 5 residents (R1, R4 and R5) reviewed for pharmacy services in the sample of 12.The findings include:1.R4's January Medication Administration Record (MAR) shows an order dated 12/8/25 for, Muro 128 Ophthalmic Ointment 5%-Instill 1 application in right eye two times a day. The MAR shows that he did not receive it on 1/12 (PM dose) and 1/30 (AM dose) and 1/31 (AM dose). R4's February MAR shows that he didn't receive it on 2/1/26.R4's Order-Administration Note dated 1/12 shows, Solution available however responsible party/POA is awaiting the ointment as ordered. R4's Order-Administration Note dated 1/30, 1/31 and 2/1 shows, medication not available. On 2/9/26 at 10:41 AM, V12 (Registered Nurse) said that she has worked at the facility for two weeks and R4 has never had Muro ointment available to administer until just the other day. V12 said that she did call pharmacy but it never came. V12 said that she would just sign it out as administered even though she didn't have it because R4's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-11 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure significant medications were administered as ordered for 2 of 5 residents (R4 and R5) reviewed for medication administration in the sample of 12.The findings include:1.R5's Nurse Practitioner Note dated 2/5/26 shows that R5 was diagnosed with a pulmonary embolism (blood clot in the lung) on 11/4/25 and is to continue her Lovenox (Enoxaparin- an anticoagulant used to treat and prevent blood clots) 100 milligrams (mg) twice a day.On 2/5/26 at 1:07 PM, R5 said that she recently had a blood clot in her lung and was put on a blood thinner to prevent additional clots. R5 said that the facility is constantly running out of her medications. R1 said that she has missed multiple doses. R5's January Medication Administration Record (MAR) shows an order starting 1/2/26 for Enoxaparin Sodium Injection 100 mg/mL (milliliter)-Inject 100 mg subcutaneously two times a day for anticoagulant. R5's MAR shows that she did not receive a dose on 1/2/26 (PM dose), 1/19/26 (AM and PM dose), 1/20/26 (PM dose), and 1/26/26 (AM and PM dose).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-11 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a respiratory viral panel was performed as ordered for 1 of 5 residents (R4) reviewed for laboratory services in the sample of 12.The findings include:R4's Nurse Practitioner Progress Notes dated 2/5/26 shows, Acute Cough. respiratory viral panel R4's Physician's Order Sheet shows an order dated 2/5/26 for a respiratory viral panel written by the prescriber. On 2/10/26 at 2:52 PM, V11 (Nurse Practitioner) said that R4 had a cough so she ordered a respiratory viral panel to make sure that he did not have a virus that was causing the cough. V11 said that she put the order into the computer and told the nurse as well. V11 said that she has not seen the results of the test and does not know if it was done or not. On 2/11/26 at 10:45 AM, V2 (Director of Nursing) said that if a provider orders a respiratory viral panel, the nurse should collect the specimen and notify the laboratory that the specimen needs to be picked up and fill out a laboratory requisition form. V2 said that she could not find any evidence that a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
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- Potential for harm · D2026-02-11 · tag F0776 — isolatedProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to obtain a STAT (immediate) chest x-ray as ordered for 1 of 5 residents (R4) reviewed for radiology services in the sample of 12.The findings include:R4's Nurse Practitioner Progress Notes dated 2/5/26 shows, Acute Cough. Chest x-ray R4's Physician's Order Sheet shows an order dated 2/5/26 for a stat chest x-ray written by the prescriber. On 2/10/26 at 2:52 PM, V11 (Nurse Practitioner) said that R4 had a cough so she ordered a chest x-ray to make sure R4 did not have pneumonia due to his history of chronic bronchitis and pneumonia. V11 said that she put the order into the computer and told the nurse as well. V11 said that she has not seen the results of the x-ray and does not know if it was done or not. On 2/11/26 at 10:45 AM, V2 (Director of Nursing) said that if a provider orders a stat x-ray, the nurse calls the x-ray provider and orders the x-ray. V2 said that they typically come out and perform the x-ray within four hours. V2 said that the results are usually received that same day. V2 said that she could not find any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-28 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to notify a resident's family and nurse practitioner after the resident fell. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 5. The findings include:R1's admission Record (Face Sheet) showed an original admission date of 5/13/25 with diagnoses to include but not limited to dementia, pubic fracture (onset date 6/27/25), osteoarthritis (joint cartilage breakdown), right shoulder bone density disorder, and spinal stenosis. On 1/22/26 at 12:30 PM, R1 was in bed, asleep, and did not awaken to her name. R1 had faded bruising to the left side of her face; the remainder of her body was covered in a blanket. R1's 1/15/26 Nurse's Note from 7:17 PM showed, Resident with fall from bed at 1610 (4:10 PM) while attempted self-transfer and fell to floor on her left side and bumped the small dresser. Small bruise on left side of forehead. (note authored by V7 Registered Nurse) On 1/21/26 at 1:57 PM, V7 Registered Nurse stated she did not notify R1's family of the fall on 1/15/26 until the next…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-26 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to identify and assess a resident with a change of condition and requiring medical intervention. This applies to 1 of 3 residents (R1) reviewed for change of condition in the sample of 5. The findings include: R1's EMR (Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] with diagnoses including Esophageal Cancer, Lung Cancer with Brain metastasis, Anxiety, Chronic Obstructive Pulmonary Disease and Dyspnea. R1's Progress Notes dated 12/18/25 states, Resident called 911 and had himself taken to (Local) Hospital. In stable condition at time of departure .The 911 Ambulance Run Report states, (Ambulance) dispatched to the location for the person with trouble breathing. Upon arrival crew found pt in his nursing home bed A&O x3 with a GCS (Glasgow Coma Scale) of 15 (Fully Alert) in obvious respiratory distress. T53(?) had arrived PTOA(?) and started care. Pt stated that he had been attempting to contact the nurses at the nursing home…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for residents that require staff assistance for incontinence care and/or toileting for 2 of 5 residents (R2, R5) reviewed for ADLs in the sample of 7. The findings include: 1. R2's care plan dated 5/20/25 showed R2 required substantial assistance from staff to complete personal hygiene and toileting ADLs. R2's resident assessment dated [DATE] showed R2 was incontinent of urine and stool. On 6/23/25 at 8:31 AM, R2's call light was on and flashing. On 6/23/25 at 8:42 AM, R2's call light remained on. R2 stated, This is a joke. I have had my call light on since 7 AM. I am soaked. My bed is wet and I need to be changed. R2 stated his incontinence brief was last changed around 10 PM on 6/22/25. On 6/23/25, from 8:42 AM-9:18 AM, R2's call light remained on and flashing. At 9:18 AM, V3 Certified Nursing Assistant (CNA) entered R2's room to deliver his breakfast tray. V3 spoke with R2, delivered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for transfers in the sample of 7. The findings include: R1's transfer record printed 6/24/25 showed as of 5/6/25, R1 required the use of a mechanical (hoyer) lift with the assistance of two staff for all transfers. On 6/23/25 at 2:16 PM, V9 Certified Nursing Assistant stated on on 6/11/25, during the evening shift, he transferred R1 from her wheelchair to bed, by himself, using only a gait belt. V9 stated he had been off of work from 5/11/25-6/9/25, due to having surgery. V9 stated, When I came back to work, I didn't realize (R1's) transfer status had changed. I didn't know she was a hoyer lift. That day she was tired and wanted to go back to bed. I lifted her up and put her into bed. On 6/23/25 at 1:35 PM, V11 Restorative Nurse stated R1's transfer status changed from using a sit-to-stand lift to needing a hoyer lift with the assistance of two staff in May 2025. V11 stated, (R1) was declining and becoming weaker. The sit-to-stand was no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-24 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 sufficient nursing staff to meet the needs of the residents for 3 of 6 residents (R2, R3, R5) reviewed for sufficient staffing in the sample of 7. The findings include: 1. R2's care plan dated 5/20/25 showed R2 required substantial assistance from staff to complete personal hygiene and toileting ADLs. R2's resident assessment dated [DATE] showed R2 was incontinent of urine and stool. R2's June 2025 Medication Administration Record (MAR) showed the following medication orders for R2: a) Lyrica 75 mg (milligrams), give one tablet three times a day at 9:00 AM, 1:00 PM, and 5:00 PM. b) Rifaximin 550mg, give one tablet twice a day at 9:00 AM and 5:00 PM. c) Senna (no dose noted), give one tablet twice a day at 9:00 AM and 5:00 PM. d) Sodium Chloride 1 gram per tablet, give two tablets three times a day at 9:00 AM, 1:00 PM, and 5:00 PM. On 6/23/25 at 8:31 AM, R2's call light was on and flashing. On 6/23/25 at 8:42 AM, R2's call light…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to accurately administer medications to meet the needs of the residents for 3 of 4 residents (R2, R3, R4) reviewed for medication administration in the sample of 7. The findings include: 1. On 6/23/25 at 11:00 AM, V12 (Family of R4) stated staff are to be administering an antifungal medication (Nyamyc Powder) daily to areas of R4's body due to a skin rash. V12 stated, Staff don't apply it everyday like they should. R4's May 2025 and June 2025 Medication Administration Records (MAR) both showed an order for R4 to receive Nyamyc External Powder 100000 units/gram, apply powder to groin topically twice a day at 6:00 AM and 9:00 PM. R4's May 2025 MAR showed R4 was not administered a dose of the medication on 5/22/25, 5/25/25, and 5/26/25. R4's June 2025 MAR showed R4 was not administered a dose of the medication on 6/13/25, 6/15/25, 6/21/25, and 6/22/25. On 6/24/25 at 10:16 AM, V2 Director of Nursing (DON) stated if a medication was not signed off and/or documented in a resident's MAR by nursing staff, it meant the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-24 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to administer medications as ordered (at ordered times). There were 30 opportunities with 6 errors resulting in a 20% error rate. This applies to 2 of 3 residents (R2, R3) observed in the medication pass. The findings include: 1. R2's June 2025 Medication Administration Record (MAR) showed the following medication orders for R2: a) Lyrica 75 mg (milligrams), give one tablet three times a day at 9:00 AM, 1:00 PM, and 5:00 PM. b) Rifaximin 550mg, give one tablet twice a day at 9:00 AM and 5:00 PM. c) Senna (no dose noted), give one tablet twice a day at 9:00 AM and 5:00 PM. d) Sodium Chloride 1 gram per tablet, give two tablets three times a day at 9:00 AM, 1:00 PM, and 5:00 PM. On 6/23/25 at 10:23 AM, V4 Registered Nurse (RN) administered R2's 9:00 AM doses of Lyrica, Rifaximin, Senna, and Sodium Chloride. 2. R3's June 2025 Medication Administration Record (MAR) showed the following medication orders for R3: a) Metoprolol Tartrate 25mg, give one tablet twice a day via gastrostomy tube at 9:00 AM and 5:00 PM. b)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-27 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure dressing changes and/or intravenous (IV) tubing changes were completed to decrease the potential for infection for 2 of 2 residents (R1 and R2) in the sample of 2 with central lines. The findings include: On 5/27/25 at 9:38 AM, R1's PICC (peripherally inserted central catheter) insertion site to his right upper arm was dressed, but it was not labeled with a date or time. R1 had antibiotics infusing and the tubing was not labeled with a date or time. R1 said the staff do not change his PICC dressing every week as is required. On 5/27/25 at 10:25 AM, R2 had antibiotics infusing via his PICC line. The tubing was not labeled with the date or time. R2 said staff had not changed his PICC dressing for almost two weeks and the IV medication tubing is supposed to be changed every 24 hours, but it is four days old. On 5/27/25 at 10:34 AM, V6, RN, said they can use the same IV tubing for 72 hours, but he changes the tubing every day, so he does not date/time the tubing. V6 said PICC dressing changes are 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.
- Potential for harm · Dcited before2025-05-27 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to administer intravenous (IV) antibiotics as ordered by the physician for 2 of 2 residents reviewed for intravenous therapy in the sample of 2. The findings include: On 5/27/25 at 10:25 AM, R2 said he is supposed to get IV (intravenous) antibiotics twice a day. R2 said he missed an entire day of antibiotics, both doses, because the medication did not get ordered. On 5/27/25 at 9:35 AM, V5, Registered Nurse (RN), said R1 has IV antibiotics ordered every 12 hours. On 5/27/25 at 10:34 AM, V6, RN, said R2 gets IV antibiotics every 12 hours. V6 said once the medication administration is started, he charts it on the EMAR (electronic medication administration record). V6 said if a medication is not signed off, that means it has not been given. On 5/27/25 at 12:25 PM, V4, LPN (licensed practical nurse), said R2 was on IV antibiotics every 12 hours at 9:00 AM and 9:00 PM. V4 said she checked for R2's IV antibiotics (Vancomycin) and there was no more. V4 said she called V2, DON (director of nursing), V2, and they looked together. They…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-05-20 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to maintain a written grievance and follow their policy for 1 of 3 residents (R2) reviewed for grievances in the sample of 9. The findings include: On 5/16/25 at 11:31 AM, V20 (R2's daughter) followed the surveyor down the hallway and stated, I filed the complaint. I was upset that my mom's legs looked like that and I filed a grievance on Friday (5/9/25). I filled out the facility's form and turned it in to [V16 (Receptionist)]. I didn't receive any follow-up from [V1 (Administrator)]. I just wanted to make sure the grievance wasn't lost. This wouldn't be the first time they lost a grievance I filed. The ADON (V3) was very helpful that day and provided care to my Mom. I ended up following up on the grievance with Social Services on the following Monday (5/12) or Tuesday (5/13). I can't remember the exact date. The ADON called me with an update on my Mom's skin, but she was very wishy washy. I was never notified what happened to that CNA (Certified Nursing Assistant) and I've seen her around the facility. It would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to safely position a dependent resident in a manner to prevent minor injury for 1 of 3 residents (R2) reviewed for safety in the sample of 9. The findings include: On 5/15/25 at 11:27 AM, R2 was reclined at approximately 45-60 degrees in the reclining wheelchair. R2's knees are contracted, pulling here heels up towards her buttocks. This position of the reclined wheelchair made her knees higher than the level of the dining room tables. R2 had bilateral heel protectors on and a donut pillow between her knees. V11 (CNA) parked R2 diagonally next to the table. R2's kneecaps and top of her shin were above the level of the table and her mid shin area was even with the table edge. (This positioning could easily have caused skin breakdown if pushed up to the table in this position.) The table was a square pedestal table. R2 smiled and was able to provide her name, but was unable to provide any details related to her legs. On 5/16/25 at 9:29 AM, V20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to adequately store food items by not properly labeling and/or dating items. This failure has the potential to affect all 102 residents who currently reside in the facility. Findings include: On 04/22/2025, upon entering facility, V1 (Administrator) indicated census of 102 in-house. Facility provided a completed CMS 802 form that indicated in-house resident census of 102. On 04/22/2025 at 10:32 AM, surveyor conducted initial kitchen tour with V4 (Dietary Manager) with the following observations. At 10:34 AM, upon entering walk in freezer #1, observed on an upper shelf to the left of freezer door, an undated and opened clear plastic bag with mixed vegetables that was halfway filled with vegetables, and an undated cardboard box which contained an inner clear plastic bag that was opened and visibly sticking out from the top of box. This box was half filled with frozen hot dogs that were not properly sealed with frost visible to several of the hotdogs within the bag. Also observed a 3 gallon sized, brown tub of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for 2 of 5 residents (R58, R47) reviewed for pressure ulcers in the sample of 62. The findings include: 1. R58's face sheet printed on 4/23/25 showed diagnoses including but not limited to hypoglycemia, tremors, anxiety disorder, schizophrenia, and mild cognitive impairment of unknown etiology. R58's facility assessment dated [DATE] showed staff assistant required for toilet hygiene, transfers, and bed rolling. The same assessment showed R58 is always incontinent of urine and bowel. R58's pressure ulcer risk assessment dated [DATE] showed a moderate risk. R58's order summary report showed an order dated 8/9/23 for a low air loss mattress on the bed. R58's most recent weight dated 4/4/25 showed 111.4 pounds. On 4/22/25 at 11:46 AM, R58 was in bed and lying on her back. R58 said she had a sore on her upper buttock in the past but she thought it was healed. R58 said she never gets out of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the safety of a resident while smoking for 1 of 2 residents (R33) reviewed for smoking in the sample of 62. The findings include: R33's admission Record, provided by the facility on 4/24/2025, showed she had diagnoses including, but not limited to, anxiety disorder, major depressive disorder, chronic pain syndrome, immobility syndrome (paraplegic), localized edema, bipolar disorder, nicotine dependence, and alcohol abuse. R33's care plan initiated on 3/26/2025 showed she is a smoker and expresses the desire to smoke at the facility. The care plan showed R33 had been assessed according to facility policy and had been determined to be a safe smoker, capable of following the applicable rules. The care plan showed Educate the resident concerning .not giving or trading cigarettes to peers, and the health and safety-related risks associated with smoking. On 4/24/2025 at 10:12 AM, R33 was sitting in her wheelchair outside in the courtyard.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 system in place to ensure all residents received their meal for 1 of 5 residents reviewed for nutrition and dining in the sample of 62. The findings include: On 4/22/25 at 11:57 AM, residents were sitting in the 300 dining room waiting for lunch trays. V13 Certified Nursing Assistant (CNA), and V16 CNA placed meal tickets on the table in front of the residents. The meal tickets showed the residents name and type of diet they can have. On 4/22/25 at 12:05 PM, V13 and V15 CNA were in the dining room placing bowls of soup in front of residents. On 4/22/25 at 12:12 PM, V13 and V15 were serving food to residents in the 300 hall dining room. V13 would bring a plate of food and sit it down on the table in front of the resident. Residents were being served randomly. One resident served at one table and then a resident at a different table, back and forth. Most residents were sitting at a long table in the middle of the dining room. R31 was seated on the side, at the end of the long table. Everyone at her table…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure physician prescribed medications were administered as ordered for 3 of 3 residents (R29, R204, R199) reviewed for medication administration in the sample of 62. The findings include: 1. R29's face sheet printed on 4/24/25 showed diagnoses including but not limited to bilateral osteoarthritis of knee, dysphagia (difficulty swallowing), chronic pain, hypertension, spinal stenosis, left eye blindness, and benign prostatic hyperplasia. On 4/22/25 at 12:23 PM, R29 was seated in the 500-unit group dining room with a tablemate directly across from him. R29 had a medication cup next to his lunch plate and there were approximately 10 assorted colored pills inside. R29 stated he takes his noon time medications by himself at lunch time most days. There were no nurses present in the dining room. 2. R204's face sheet printed on 4/24/25 showed diagnoses including but not limited to rhabdomyolysis (breakdown of muscle tissue), hypothyroidism, hyperkalemia, dementia with anxiety, heart failure, chronic kidney disease,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff wore personal protective equipment when providing care for residents on enhance barrier precautions (EBP) and carrying soiled linen from a room for 3 of 3 residents (R47, R23, & R203) on transmission based precautions in the sample of 62. The findings include: 1. On 4/22/25 at 10:54 AM, there was an enhanced barrier precaution (EBP) sign under R47's name and next the doorway of her room. There was a three drawer container sitting on the floor next to R47's doorway to her room. R47 was in bed laying on her left side and had a bandage to her right elbow. R47 had oxygen on at 2 liters via nasal canula. V13 Certified Nursing Assistant (CNA) had a mask on and no other personal protective equipment (PPE). V13 and came into R47's room to check her feet to see if they were offloaded. V13 pulled back the residents blankets and the resident had an offloading boot in place to her right foot/heel. V13 removed the boot and R47 had a gauze…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to consistently implement treatments and assessments for R3's Left Ventricular Assistive Device (LVAD) for 1 of 2 residents (R3) reviewed for quality of care in the sample of nine. The finding include: On 04/16/25 at 10:10AM, R3 was lying in bed. R3 had an undated 4 inch by 4-inch gauze dressing covered with a clear dressing to the right abdominal area. On 04/16/25 at 10:10AM, R3 said, this is the worst place I have ever been. I just got out of the hospital. I was in pain and I had to call 911 to get transported to the hospital. The LVAD Coordinator at the hospital took pictures of my dressing because it was so dirty. My LVAD dressing is supposed to be changed every day. On 04/16/25 at 11:10AM, V8 Licensed Practical Nurse (LPN) said, he (R3) went out on Saturday, they sent out a new order for the dressing to be changed every other day. I got the order from the nurse at the hospital verbally. On 04/16/25 at 11:51AM, V9 Nurse Practitioner (NP) said, R3's LVAD orders are managed by the LVAD clinic. R3 has a history…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-21 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to adequately assess and monitor a resident for skin integrity issues and failed to obtain a physician's order for wound care for 1 of 4 residents (R4) reviewed for quality of care in the sample of 4. Findings include: R4's medical record indicated she admitted to the facility on [DATE] with a past medical history not limited to: anorexia, congestive heart failure, gout, hypertension, dementia, and Parkinson's Disease. Review of wound report summary as of 03/21/2025 at 10:29 AM documented for R4: right shoulder with rashes, few rashes resolved, some with scabs. No complaint of pain or itching. Treatment changed to triamcinolone (corticosteroid topical medication) cream. On 03/21/2025 at 11:27 AM, R4 indicated she has a rash to her upper arms that itches at times then proceeded to pull up the sleeve of her sweater on her right arm. Surveyor observed reddened areas and scratch marks with multiple small, scabbed areas throughout R4's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-11 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 include a resident in her care plan meetings for 1 of 4 residents (R7) reviewed for resident rights/right to participate in their plan of care in the sample of 12. The findings include: R7's current care plan dated showed R7 was admitted to the facility, on 10/10/24, with diagnoses of diabetes, right leg above-the-knee (AKA) amputation, and wounds to her sacrum and left foot. The plan showed R7 had no advanced directives and/or POA (power of attorney). The plan showed R7 had a hearing impairment. (R7) is able to express personal needs/wants Speak slowly and clearly (to R7) . R7's resident assessment dated [DATE] showed R7 was cognitively intact. On 3/10/25 at 9:50 AM, R7 was seated in a wheelchair in her room. R7 was interviewed by this surveyor with no hearing difficulties noted from R7 as this surveyor spoke slowly and directly into R7's right ear. This surveyor did not have to yell to be heard by R7. R7 stated she was upset because they had a meeting…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent/heal pressure ulcers for 2 of 3 residents (R1 and R11) reviewed for wounds in the sample of 12. The findings include: On 3/10/25 at 10:51 AM, R1 was lying in bed. He did not have a low air loss mattress. On 3/10/25 at 1:41 PM, R11 was lying in bed. She did not have a low air loss mattress. R1's admission Record dated 3/11/25 shows R1 was admitted to the facility on [DATE]. R1's Wound Assessment Details Report dated 2/27/25 shows R1 was admitted with a Stage 4 pressure ulcer of his sacrum measuring 5.0 centimeters (cm) by 6.5 cm by 2.0 cm and a Stage 3 pressure ulcer of his left ischial tuberosity measuring 5.0 cm by 5.2 cm by 0.30 cm. R1's Order Summary Report dated 3/11/25 shows an order for a pressure relieving mattress ordered on 2/26/25. R11's admission Record dated 3/11/25 shows R11 was admitted to the facility on [DATE]. R11's Wound Assessment Details Report dated 2/26/25 shows R11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure a resident was supervised while ambulating which contributed to the resident sustaining a fall for 1 of 3 residents (R8) reviewed for supervision/falls in the sample of 12. The findings include: A facility fall incident report dated 2/27/25 showed R8 sustained an un-witnessed fall in the facility. The report showed, Resident was ambulating by herself in the hallway when writer heard her start crying and observed resident lying on the floor on her right side . R8 was unable to state what happened due to her impaired cognition. Swelling and redness was noted to R8's forehead. R8 was sent to the hospital for an evaluation post-fall. R8 returned to the facility, from the hospital, with no injuries noted from the fall. R8's current care plan showed R8 was at risk for falls due to her diagnoses of dementia, Alzheimer's Disease, recurrent psychosis, and anorexia. The plan showed R8 required staff supervision for transfers and toileting. The plan showed, She is able to walk with no assistive device 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.
- Potential for harm · Dcited before2025-01-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure a residents nasal spray was obtained from pharmacy and administered for 1 of 3 residents (R2) reviewed for pharmacy services in the sample of 5. Findings include: R2's Physician Order Summary shows an active order for Flonase Allergy relief nasal suspension 1 spray each nostril one time a day at 9:00 AM, for allergy with a start date of 1/18/25. R2's Medication Administration Summary from 1/1/25-1/31/25 shows on 1/18/25, 1/19/25 and 1/21/25 the Flonase nasal spray was not administered and it was documented as 11 (not available). On 1/20/25 the medication had a check mark as if it was given even though it was not at the facility. On 1/22/25 at 9:33 AM, V4 (Licensed Practical Nurse/ LPN) was administering medications to R2 she was not able to administer the Flonase due to it being not available at the facility. V4 said that when a medication is not sent from the pharmacy they should follow up and try to find out why it was not sent. V4 said she will find out today. At 11:40 AM, V4 said the pharmacy told…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-16 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain physician orders upon admission. This applies to 1 of 1 residents (R1) reviewed for admission orders in the sample of 7 . Findings include: R1's admission Record dated 12/16/2024 shows an original admission date of 12/3/2024. On 12/16/2024 at 10:13AM, V10 Licensed Practical Nurse (LPN) said he admitted [R1] on 12/3/2024. V10 said he did not call a provider to obtain orders upon admission for wound care. V10 said [R1] had wounds present upon admission. On 12/16/2024 at 11:26AM, V2 Director of Nursing (DON) said upon admission the nurse will call the provider to get orders appropriate for the residents' care needs. R1's Order Summary Report dated 12/16/2024 shows no active orders for wound care were entered during R1's admission on [DATE]. The facility provided admission of a Resident revised 9/1/2024 states . Residents are admitted to the facility under orders of the attending physician.
- Potential for harm · Dcited before2024-12-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess or provide wound care to a resident admitted with wounds. This applies to 1 of 3 residents (R1) reviewed for wounds in the sample of 7. Findings include: R1's admission Record dated 12/16/2024 shows an original admission date of 12/3/2024 and a readmission date of 12/6/2024. R1's Census List dated 12/16/2024 shows actual admission on [DATE] at 8:18PM, discharge Against Medical Advice (AMA) on 12/4/2024 at 10:00AM, re-admission [DATE] at 11:39AM, and discharge 12/6/2024 at 3:36PM. On 12/16/2024 at 10:13AM, V10 Licensed Practical Nurse (LPN) said he admitted [R1] on 12/3/2024. V10 said [R1] had wound present upon admission on his chest, back, and part of his abdomen. V10 said he did not change [R1's] dressing upon admission. On 12/16/2024 at 11:26AM, V2 Director of Nursing (DON) said the nurse does an initial assessment upon admission, if the resident has wounds, they will follow the wound protocol. V2 said if the resident has multiple open areas,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have quarterly care plan conferences. This applies to 3 of 5 residents (R1, R2, R4) reviewed for care plan conferences in the sample of 5. Findings include: 1. On October 16, 2024 at 10:19 AM, R1 stated, he has never attended/had a care plan conference since he's been at the facility. R1's face sheet shows, he was admitted to the facility on [DATE]. R1's electronic medical record (EMR) does not show any documentation of care plan conferences being done since R1 was admitted to the facility. On October 16, 2024 at 12:55 PM, V3 (Social Service Director/SSD) stated, R1 refuses to do care plan conferences. At 2:58 PM , V3 (SSD) confirmed R1's EMR did not show any documentation of his refusals or that care plan conference was done until she added the information on October 16, 2024. R1's minimum data set (MDS) dated [DATE] shows, he is cognitively intact. 2. On October 16, 2024 at 10:40 AM, V7 R2's son/POA (power of attorney) stated, they have not had a care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-09-25 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 follow their contact isolation policy by failing to implement contact isolation precautions for a resident (R3) with a suspected contagious skin rash. The facility failed to ensure a resident (R3) diagnosed with scabies remained isolated from other residents. The facility failed to disinfect and sanitize a communal shower room after a resident (R3) diagnosed with scabies was showered in the room, failed to handle the personal belongings of a resident (R3) diagnosed with scabies, in a manner to prevent cross contamination to others (R7) and failed to ensure housekeeping staff wore the required personal protective equipment (PPE) when cleaning the room of a resident (R6) on contact isolation for a rash. These failures have the potential to affect all 95 residents in the facility. Findings include: The Facility Data Sheet dated 9/25/24 showed a resident census of 95. A facility's Skin Check/Line list printed on 9/25/24 showed an outbreak of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility staff failed to immediately report an allegation of sexual abuse to the abuse coordinator for 1 of 3 residents (R1) reviewed for abuse in the sample of 6. The findings include: On 6/5/24 at 9:45 AM, R1 said a month ago she was raped by 4 black men. R1 said she was not sure if it was just in her mind, but she knew she was drugged and raped and she was soaked and wet. R1 said the next morning V9 (Agency Certified Nursing Assistant-CNA) came to her room to change her and said, it smelled like semen here. On 6/5/24 at 12:52 PM, V9 (Agency CNA) said she worked with R1 twice, 2/18/24 and 3/16/24. V9 said she did not smell any semen when she took care of R1, however, R1 told her (cannot recall specific date but it was either February or March) that four black men raped R1. V9 said R1 told the story to her more than once. V9 thought she reported this to the nurse but cannot recall who the nurse was or when she reported the sexual allegation to the nurse. On 6/5/24 at 2:20 PM, V2 (Director of Nursing-DON) said all allegations of abuse should…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure the safety of a resident when facility staff failed to recognize that a resident (R1), did not return to the facility after being out of the facility on a community/day pass. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. The findings include: R1's care plan dated 4/19/24 showed R1 was admitted to the facility, for rehabilitation, due to a pelvic and hip fracture she sustained from a fall. The plan showed R1 was to walk only with the assistance of staff. R1 required assistance from staff to transfer from surface to surface. R1 propelled herself in a wheelchair. The plan showed R1 was cognitively intact. R1 was homeless prior to her fall. A State Survey Agency Health Care Facility Complaint Form dated 4/30/24 showed R1 was reported missing to a local police department on 4/30/24 at 8:44 PM. The report showed the facility had contacted the local police department to report R1 had been missing since 11:00 AM. The report showed R1 had been signed out of the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure medications were administered according to professional standards for 2 of 3 residents (R1, R8) reviewed for medications in the sample of 8. The findings include: 1. On 4/30/24 at 9:55 AM, R1 said a couple weeks ago, a night nurse left his 12:00 AM medications on his table under the TV. R1 said he had fallen asleep in his chair and when he woke up after 1:00 AM he went to the nurse and asked for his medications and she said she left them in his room on his table. On 4/30/24 at 2:40 PM, V5 Registered Nurse said when she was making her rounds one night, R1 was asleep in his chair. V5 said she didn't want to wake him up to take his medications, so she left in on his table under his TV. R1's Progress Note dated 4/10/24 by V5 shows Noted resident sleeping on his motorized wheelchair during initial rounds. Around 1:00 AM, resident wheeled himself outside the nurses station asking for his midnight meds then ranting out that his sleep would be late because he didn't get his meds on time. Told him that he 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.
- Potential for harm · Fcited before2024-01-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure food was at a safe temperature before serving meals by not checking the temperatures of food before serving from the steam table and by not checking the temperature of reheated food. This applies to all 67 residents residing in the facility. The findings include: On 1/29/24 at 12:00 PM, The noon meal was brought up to the Tuscany unit and placed on the steam table by V19 and V20 (Dietary Aides). V19 then plated the noon meal for resident delivery to the Tuscany, Cape Cod and [NAME] units. V19 did not take the temperature of the food before or during the serving of the food. V20 used the microwave to heat turkey that he got from the unit refrigerator. V20 did not cover the turkey nor did he check the temperature of the turkey before it was delivered to the residents. On 1/29/24 at 12:41 PM, V19 said that she should have taken food temperatures before serving the food but she forgot. At 12:44 PM, V18 (Dietary Manager) said that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-31 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to change gloves and wash hands to prevent the spread of infection for one resident (R62). The facility also failed to place three residents (R122, R45, R35) on enhanced barrier precautions. These failures affect 4 of 17 residents (R62, R122, R45, R35) reviewed for infection control in the sample of 17. The findings include: 1. On 1/29/24 at 10:15 AM V13 (Certified Nursing Assistance-CNA) provided incontinence care to R62 after having a bowel movement. The CNA applied a new incontinent brief to R62, turned R62 from side to side to adjust R62's clothing, and adjusted R62 in bed, while wearing the same soiled gloves and without washing her hands. On 1/30/24 at 1:15 PM, V21 (Infection Control Nurse-IP) said staff should change their gloves and wash their hands when cleaning from dirty to clean to prevent the spread of infection. If cleaning up stool, staff should change their gloves before moving to a clean area or touching anything to prevent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-31 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide ongoing, direct monitoring of the resident's condition during the use of a physical restraint. The facility failed to implement interventions to attempt to reduce the use of a physical restraint. These failures apply to 1 of 1 resident (R5) reviewed for physical restraints in the sample of 17. The findings include: R5's current care plan showed R5 used a wheelchair waist restraint for treatment of her spasm-like movements. Her care plan showed, Anticipate and intervene for potential causes which have precipitated prior falls or accidents. Ensure resident is positioned correctly with proper body alignment while restrained . Evaluate use for alternatives to restraint, need for ongoing use . The facility's fall incident reports dated 9/18/23 and 12/1/23 showed R5 sustained unwitnessed falls, onto the floor, while still restrained in her wheelchair by her waist restraint. On 9/18/23, R5 was found lying on the floor, with her wheelchair on top of her, while she remained restrained in the chair. On 12/1/23,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide ADL (activity of daily living) assistance for residents that require staff assistance for toileting/incontinence care for 2 of 17 residents (R13, R26) reviewed for ADL's in the sample of 17. The findings include: 1. R13's current care plan showed R13 is severely cognitively impaired due to her diagnosis of dementia. The plan showed R13 is incontinent of bladder and bowel and R13 requires the substantial assistance of at least one staff for toileting/incontinence care. On 1/29/24 at 9:20 AM, R13 was asleep in a wheelchair in the dining room. On 1/29/24 at 9:30 AM, R13 remained asleep in her wheelchair in the dining room. On 1/29/24 at 11:00 AM, R13 remained in her wheelchair in the dining room. On 1/29/24 at 11:30 AM, R13 was asleep, with her head on the table, in the dining room. On 1/29/24 at 1:00 PM, R13 remained seated in the dining room, eating lunch. On 1/29/24 at 1:28 PM, R13 was wheeled into her room by V3 Certified Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-31 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide the necessary care and services to a resident when a new, non-pressure wound was identified for 1 of 17 residents (R19) reviewed for necessary care and services in the sample of 17. The findings include: R19's current care plan showed R19 was at high risk for skin breakdown due to his previous history of pressure injuries, diagnosis of CVA/stroke, being incontinent of bowel and bladder, and requiring the extensive assistance of staff for transfers and repositioning. The plan showed, Inform the resident/family/caregivers of any new area of skin breakdown. On 1/29/24 at 9:57 AM, V10 Certified Nursing Assistant (CNA) provided incontinence care to R19 as he was incontinent of urine and stool. A small, opened area was noted to R19's left upper buttock. V10 CNA pointed to R19's left buttock and stated, Oh, he does have an open area. V10 placed R19 in a clean incontinence brief and left R19's room. On 1/29/24 at 12:37 PM, V6 Licensed Practical Nurse (LPN) stated R19 did not have any pressure injuries or open…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-31 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — the official record, unedited, 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 interventions to reduce the risk of pressure ulcer development for 1 of 5 residents (R56) reviewed for pressure ulcers in the sample of 17. The findings include: R56's current Care Plan on 01/30/24 shows, R56 is at risk for skin breakdown. Offloading of bilateral heels when in bed every shift and as needed. On 01/30/24 at 10:23 AM, R56 was lying in bed. R56's left and right heels were resting on the mattress. R56's pressure reduction heel protectors were not in place. On 01/30/24 at 10:30 AM, V14 RN-Registered Nurse said, the heel protectors are to prevent pressure sores from developing. R56's Pressure Sore Risk assessment dated [DATE] shows, High Risk for pressure ulcer development.
- Potential for harm · D2024-01-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a physician ordered palm protector for 1 of 5 residents (R3) reviewed for range of motion in the sample of 17. The findings include: R3's Physician's Orders dated 06/24/2023 at 2:11 PM, shows, palm protector grip to left hand. On at all times. May remove for skin check, ROM-Range of Motion and Hygiene. R3's Minimum Data Set, dated [DATE] shows, Brief Interview for Mental Status mild impairment. Functional Assessment: Upper and lower impairment one side. On 01/29/24 at 11:45 AM, R3 was lying in bed sitting up watching television. R3's left fingers were contracted with his fingertips touching the palm of his hand. R3 did not have a palm protector grip. At this time, R3 said, they are supposed to provide a palm protector grip for my left hand. The restorative will put the palm protector grip in my hand, tell me to squeeze it, then go out in the hall and start playing on her phone. I squeeze it, see I can move my hand a little. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-31 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide dietary supplements for residents with significant weight loss for 2 of 7 residents (R31, R5) reviewed for weight loss in the sample of 17. The findings include: 1. R31's Weight Summary record showed R31 weighed 120 pounds (lbs) on 7/21/23 and 107.5 pounds on 1/17/24. This showed R31 sustained a significant weight loss of 10.4% in six months. R31's nutrition/dietician note dated 11/6/23 showed R31 had sustained a significant weight loss. The note showed, Recommend: Super cereal (fortified cereal), one serving daily at breakfast; fortified soup, one serving daily at lunch . R31's nutrition/dietician note dated 12/11/23 showed, Continue all current supplements . R31's current care plan showed continue to provide all current supplements due to her significant weight loss. On 1/29/24 at 12:46 PM, V3 Certified Nursing Assistant (CNA) was seated next to R31, in the dining room, as she ate her meal consisting of lasagna, cooked broccoli, and apple crisp. No fortified soup was noted on R31's tray. On 1/30/24 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.
- Potential for harm · Dcited before2024-01-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to administer medications according to standard of practice to 1 of 17 residents (R57) reviewed for medications in the sample of 17. The findings include: R57's facility assessment dated [DATE] show R57 has no cognitive impairment. On 1/29/24 at 10:45 AM, R57 was sitting in her room, a cup full of medications was at her bedside. R57 said this morning when the nurse V11 (Licensed Practical Nurse-LPN) gave her morning meds, she tried to take them but she felt like throwing up so she did not take them R57 said she put the meds back to the medication cup. R57 said her morning meds includes her blood pressure meds and stomach meds. R57 said she's feeling better now. This surveyor then notified the nurse-V11 (LPN) that R57's morning medications were still in her medication cup. V11 stated [R57] did take her meds, because I gave her (R57) meds. Then V11 showed this surveyor R57's electronic medical administration record (MAR) that has been signed and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to ensure gloves were changed to prevent cross contamination when providing ileostomy care for 1 of 24 residents (R40) reviewed for infection control in the sample of 24. The findings include: R40's admission Record showed R40 had an ileostomy (a surgical opening in the abdomen that allows stool to exit the body). On 03/20/23 at 10:00 AM, V4 (Certified Nursing Assistant) was emptying R40's ileostomy bag. V4 had gloves on. After the bag was emptied, V4 took a wet wipe and cleaned stool from the opening of the ileostomy bag. With the same gloves on that were used to clean the stool, V4 touched R40's shirt, R40's wheelchair, bedside table, and privacy curtain. On 03/20/23 at 11:34 AM, V4 said gloves are changed after cleaning stool before touching anything clean to prevent cross contamination. The Facility's Glove Usage policy with a reviewed date of 03/23/22 showed the objective is to prevent the spread of infection.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$370,046 in federal fines across 9 penalties. 2 Medicare payment denials on record.
- $26,155 — penalty dated 2026-06-23
- $100,175 — penalty dated 2026-04-29
- $62,940 — penalty dated 2026-01-28
- $14,759 — penalty dated 2025-04-17
- $24,856 — penalty dated 2025-01-22
- $14,255 — penalty dated 2024-12-02
- $82,675 — penalty dated 2024-09-07
- $21,041 — penalty dated 2024-07-10
- $23,190 — penalty dated 2024-01-31
- Medicare payment denial — starting 2025-02-14 for 14 days
- Medicare payment denial — starting 2024-10-04 for 13 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SERENITY ESTATES — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.2 | -1.2 vs chain |
| Health inspection | 1 of 5 | 3.0 | -2.0 vs chain |
| Staffing | 1 of 5 | 1.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 2.4 | -0.4 vs chain |
The other 4 homes this chain runs (chain average 2.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BEHMER, RUSTY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/11/2025 |
| COGLIANESE, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2024 |
| DAUGHERTY, JENNIFER | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2024 |
| GS MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2024 |
| BAKER, HOWARD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2024 |
| LINCOLNSHIRE PROPERTIES LIMITED PARTNERSHIP | Organization | ADP OF THE SNF | since 09/01/2024 |
CMS files one row per role, so the 14 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 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.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $632K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146028. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-24, 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 →
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