No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

La Bella of Mascoutah

201 South 10th Street, Mascoutah, IL 62258 · For profit - Partnership · 76 certified beds · (618) 566-8000 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$129,084 in federal fines1 Medicare payment denial
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $129,084 in federal fines (most recent 2025-08-20)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (79%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
739 N Jefferson St · (618) 566-8810 · Call to confirm hours
Pharmacy
16 E Main St · (618) 566-8521 · Call to confirm hours
Grocery
95 Mascoutah Plaza Dr · (618) 566-2118 · Call to confirm hours
Park
899 W Harnett St · (618) 566-2964 · Typically dawn to dusk
Place of worship

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 fell from 3 to 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.8%13.4%15.4%better
Long-stay residents who lose too much weight16.3%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder1.0%0.9%0.9%worse
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms19.2%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.8%3.1%3.3%better
Long-stay residents on antianxiety or hypnotic medication34.8%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine38.5%91.8%95.3%worse
Long-stay residents with pressure ulcers8.8%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control15.1%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table18.4%21.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.9%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine23.5%63.1%79.4%worse
Short-stay residents rehospitalized after admission19.9%26.1%22.6%better
Short-stay residents with an outpatient ER visit21.8%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.562.021.67worse
Long-stay outpatient ER visits per 1,000 resident days3.102.221.80worse

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.

11.1%U.S. median 10.7%
Went back to hospital
0.37U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.37 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.4–16.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified92.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.311.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.39
RN hours/ resident / day
1.04
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.65
Total nurse hours/ resident / day
0.28
RN hoursweekends
78.8%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 76 beds and averages 37.3 residents a day — about 49% occupied, or roughly 39 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.15 hrs/resident/day on weekends vs 3.86 on weekdays — 18% thinner on weekends. RN hours go from 0.43 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 79% 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

4
deficiencies at the latest standard inspection (2025-12-19)
6
at the previous standard inspection (2024-09-20)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

36 citations, most serious first. The 15 most serious are shown; the remaining 21 are one tap away and print in full.

  • Immediate jeopardy · J2025-05-20 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants prescribed for pain control to two of three residents (R1 and R2) reviewed for pain in the sample of three. This IJ began on 3/30/2025 when R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy described experienced, symptoms of medication withdrawal, pain described as being ongoing, uncontrolled, excruciating, and unbearable to her head, neck, back and both lower legs, which resulted in an emergency room treatment for pain relief. R2 described a decrease in her quality of life, along with expressions of feeling forgotten and wanting to die. Additionally, R1 who suffers from cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome too described experiencing ongoing, uncontrolled, severe pain, rated 9 on pain scale (1 to 10) to left side of his body. This failure resulted…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-09-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to assess, monitor, and provide treatments as ordered and notify a provider of maggots for 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3. This failure resulted in maggots in R1's foot wound. that R1 described as giving her the heeby jeebies. Using a reasonable person concept, maggots in a wound would cause a person to feel shame, embarrassment, anxiety, and uncleanliness for this profound, disturbing experience of parasites in a wound.1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including paraplegia, acquired absence of right leg above the knee, and pressure ulcer of left heel.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, ambulated via wheelchair, and had three stage 3 pressure ulcers that were present on admission.R1's Care Plan initiated 6/30/24 documents R1 has a wound.R1's Specialized Wound Management Note dated 7/14/25 documents R1 has left dorsal…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-08-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to order a abdominal ultrasound, urinalysis/culture and sensitivity in a timely manner for 1 (R4) of 3 residents reviewed for timeliness of care in the sample of 3. This failure resulted in a nonverbal resident (R4) being transferred to the emergency room and diagnosed with a impacted stool in the intestine that was digitally removed from her rectum, enema, IV hydration and intramuscular shot for the urinary tract infection and put on oral antibiotics. Using the reasonable person approach, this failure caused pain, discomfort and invasive interventions during a hospital visit. Findings include: R4's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including cerebral palsy, constipation and GERD.R4's Care Plan, dated 3/31/2025 documents focus bowel and bladder incontinence. Interventions: record bowel movements, frequency, and consistency. Assess any signs of discomfort, burning or itching around…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-05-20 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants prescribed for pain control to two of three residents (R1 and R2) reviewed for pain in the sample of three. This failure resulted in R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy described experienced, symptoms of medication withdrawal, pain described as being ongoing, uncontrolled, excruciating, and unbearable to her head, neck, back and both lower legs, which resulted in an emergency room treatment for pain relief. This failure also resulted in R1 who suffers from cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome too described experiencing ongoing, uncontrolled, severe pain, rated 9 on pain scale (1 to 10) to left side of his body. Findings include: 1. R1's admission Record, print date 5/14/2025, documents that R1 was admitted [DATE] and lists cervical…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-09-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to have fall interventions in place and implement progressive interventions in 3 of 7 residents (R6, R19, R36), reviewed for falls in the sample of 24. This failure resulted in R36 sustaining a head injury, requiring emergency room evaluation and treatment including but not limited to glue and adhesive skin closure strips to the right temple area. Findings include: 1. On 9/17/24 at 9:05 AM, R36 was observed in her room in a low bed with a mat to left side of the bed, the call light was behind the bed, not within reach. R36 had bruising noted to the bilateral eyebrow areas with adhesive closure strips in place to the right eyebrow area. R36 stated she fell recently and that is how she got the bruising. R36 stated she has fallen 3-4 times and has gotten hurt each time. R36 stated she tries to get up on her own and falls, unsure of why she falls, she just does. R36 stated she uses her call button when she needs help and stated it's usually…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 develop a comprehensive care plan in 3 of 4 residents (R3, R4, R12), reviewed for development of the comprehensive care plan in the sample of 12.Findings Include:Findings include: 1. On 2/26/26 at 10:35 AM, R3 was observed in her room in a reclining wheelchair, with the television on. Contractures were observed to the left hand with the fingers completely contracted to the palm of the left hand. There were not any splints/washcloths in place to aid in contracture management. R3's Face Sheet, undated, documents R3 has the following diagnoses: Intracerebral Hemorrhage, Hyperosmolality, Hypernatremia, Plasma Protein Metabolism Disorder, Unspecified Skin Changes, Pulmonary Hypertension, Age Related Debility, Urinary Retention, Protein Calorie Malnutrition, HTN (Hypertension), COPD (Chronic Obstructive Pulmonary Disease), Anorexia, and Pain. R3's MDS (Minimum Data Set), dated 1/1/26, documents R3 has severe cognitive impairment, has impairment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide positioning assistance to 2 of 3 residents (R3, R11), when reviewed for ADL (Activities of Daily Living) care provided to dependent residents in the sample of 12.Findings Include:1.On 2/26/26 at 8:40 AM, R3 was observed in the dining room, up in her reclining wheelchair being assisted with the breakfast meal.On 2/26/26 at 10:35 AM, R3 was observed in her room in her reclining wheelchair.On 2/26/26 from 8:40 AM to 1:00PM, R3 was observed in 15-30-minute increments, R3 was not repositioned during that time.On 2/26/26 at 1:30 PM, R3 was observed being assisted to bed by staff.On 2/26/26 at 1:30 PM, V4, CNA (Certified Nursing Assistant) stated she laid R3 down after breakfast, incontinent care was provided and was repositioned. V4 stated she was unsure of the exact time and did not lay R3 down or reposition her again until 1:30 PM.R3's Face Sheet, undated, documents R3 has the following diagnoses: Intracerebral Hemorrhage, Hyperosmolality, Hypernatremia, Plasma Protein Metabolism Disorder, Unspecified…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-04 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a comprehensive assessment and preference for 3 of 3 (R4, R5, R12) residents investigated for activities in a sample of 12.1. R4's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE].R4's EMR dated 9/3/25 documents a diagnosis of legal blindness, as defined in USA.R4's EMR dated 9/3/25 documents a diagnosis of anxiety disorder, unspecified.R4's EMR dated 10/3/25 documents a diagnosis of other psychotic disorders not due to a substance or known physiological condition.R4's MDS dated [DATE] documents a BIMS score of 14 out of 15. The MDS documents that the resident requires setup or clean-up assistance for roll left and right, sit to lying, lying to sitting on side of bed, and sit to stand. The MDS documents that the resident requires supervision or touching assistance for chair/bed to chair transfer and toilet transfer.R4's Care plan dated 10/24/25 documents, I prefer (Specify: to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement safety measures to prevent falls in 1 of 5 residents (R11) when reviewed for freedom of accidents in the sample of 12.Findings Include: On 2/27/26 at 9:48 AM, R11 was observed in the dining room in her wheelchair with a clear plastic lap tray in place. The tray is attached to the wheelchair with Velcro straps going from the tray to the wheelchair arm rests. The tray is easily moved and slides up/down very easily. R11's Progress Note, dated 12/19/25 at 10:07 PM: 9:25 PM, documents the following: Resident observed lying on her back/right side in dining room next to her wheelchair. No apparent physical injury; AROM (Active Range of Motion) and PROM (Passive Range of Motion) WNL (Within Normal Limits) for resident. Neuro checks initiated and WNL for resident. VSS (Vital Signs Stable) 120/78, 63, 16, 97.4, 99% RA (Room Air). 9:35 PM, DON (Director of Nurses), Administrator, POA (Power of Attorney), and MD (Medical Doctor) notified. POA would like resident to be sent to the local hospital. 9:50 AM,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-19 · tag F0725 — failed to have enough nursing staff — widespread
    Provide 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 observation, interview, and record review, the facility failed to have a sufficient number of CNAs (Certified Nursing Assistants) to care for their residents when reviewed for Nursing Services. This failure has the potential to affect all 33 residents residing in the facility. Findings Include: On 12/17/25 at 9:06 AM, there were 2 CNAs observed working. On 12/16/25 at 11:10 AM, R33 stated they don't have enough aides, it takes a long time for him to get his call light answered and to get help. On 12/17/25 at 10:55 AM, 10:59 AM, 11:15 AM, and 11:30 AM - R20's call light was on. Staff in hallway were passing by, not answering call light. On 12/17/25 at 11:41AM R20 stated she has had her call light on since 10:30 AM and no one has come into her room to help her. R20 stated, I understand that now they are getting ready for lunch, feeding the residents, but I'm tired of it, tired of waiting, they think oh it's just (R20), she'll understand, but I'm tired of waiting. I want a shower and want to get up for the day. They don't have any aides here today, I haven't even seen any. 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-12-19 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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 to serve palatable food and food cooked at the appropriate temperature when reviewed for Food and Nutrition Services. This failure has the potential to affect all 33 residents residing in the facility.Findings Include: 1. On 12/16/25 at 3:00 PM, R20 was observed and appears thin. R20 stated the food needs perked up, she couldn't eat the meals on Saturday (12/13/25), they were horrible. Sunday (12/14/25) they were a little better, so she ate. R20 stated she has lost weight and needs to gain it back but the food tastes so bad she can't eat it. R20's MDS (Minimum Data Set), dated 10/10/25, documents R20 has a BIMS (Brief Interview for Mental Status) score of 14, indicating R20 is cognitively intact. 2. On 12/16/25 at 11:20 AM, R27 stated the food tastes horrible. She is hungry but can't eat it. R27 stated they offer substitutes, but they aren't any better. R27 stated she is never offered snacks and doesn't know if they even have any. R27's MDS, dated…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-12-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the Facility failed to store foods in a manner that prevents foodborne illness and potential contamination. This has the potential to affect all 33 residents living in the Facility.Findings Include:On 12/16/2025 at 10:35 AM in the standing refrigerator there was a clear plastic container covered with plastic wrap labeled sloppy joe and a clear plastic container covered with plastic wrap labeled cheesy broccoli rice, neither container was dated. In the dry good storage area, there was an uncovered, clear plastic container with a plastic bag full of a white powdery substance that appears to be flour with label or date.On 12/17/2025 at 12:30 PM a large plastic container of dry cereal was on the bottom of a three-tier metal rolling cart uncovered with no date. On 12/17/2025 at 3:20 PM V17, Dietary Manager, stated all food stored in the refrigerator should be stored in a covered container and labeled with the date it was cooked. V17 stated food is only good for 3 days once cooked and placed in the refrigerator. V17 stated all dry good including cereal…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop a comprehensive care plan on 2 of 18 residents, (R20 and R26), reviewed for Comprehensive Resident Centered Care Plan in the sample of 25.Findings Include:1.R20's Face Sheet, undated, documents R20 has a diagnosis, in part, of Severe Calorie Protein Malnutrition. R20's Care Plan, dated 10/30/24, fails to document a care plan related to her nutritional status/needs. 2.R26's Face Sheet, undated, documents R26, has a diagnosis, in part, of (ESRD) End Stage Renal Disease. On 12/17/25 at 8:33 AM, R26 stated he receives dialysis. R26's Care Plan, dated 11/11/25, fails to document a care plan related to his diagnosis of ESRD, which requires hemodialysis. On 12/19/25 at 8:15 AM, V1 Administrator, stated care plans should be developed for each resident's specific needs and she is working on them. The Comprehensive Care Plan Policy, with a revision date of 6/25/25, documents the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to give resident showers to 3 of 5 residents (R2, R3, R5) reviewed for ADL (Activities of Daily Living) care provided for dependent residents in the sample of 5.Findings Include:1. R2's Face Sheet, undated, documents R2 has a diagnosis, in part, of Quadriplegia.R2's MDS (Minimum Data Set), dated 10/12/25, documents R2 is cognitively intact and is dependent upon staff for showers.R2's Care Plan, dated 6/3/25, documents R2 has an ADL self-care deficit and requires 1-2 assist with showers.R2's Shower Sheets, fails to show any documentation of a shower given/offered from 9/9/25 until 9/22/25 and none documented in 11/2025On 12/2/25 at 10:35 AM, R3 stated they don't have enough CNAs (Certified Nursing Assistant), and when you don't have enough CNAs, you don't get your showers.2. R3's Face Sheet, undated, documents R3 has a diagnosis, in part, of Cerebral Infarction with Hemiparesis/Hemiplegia.R3's MDS, dated [DATE], documents R3 is cognitively…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure quality/safe transportation for 1 (R2) of 4 residents reviewed for unsafe transportation in the sample of 7. This failure resulted in R2's fractured right leg coming off R2's foot pedals and R2 dragging fractured right leg on ground. Findings include:R2's face sheet documents an admission date of 9/11/2025. Diagnosis include Encounter for other Orthopedic Aftercare, Infection Following a Procedure, Superficial Incisional Surgical Site, Fracture of Lower End of Right Femur, Dementia, Morbid Obesity. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent for transfers and mobility. R2's care plan updated currently has an alteration in her mobility and needs assistance due to limited range of motion due to non-weight bearing to right lower to right lower extremity status post-surgery. R2 requires mechanical lift for transfers. Interventions include: Cueing, reorientation as needed. Monitor/document…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 21 citations
  • Potential for harm · Dcited before2025-10-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to monitor and document pressure ulcer development for 1 (R2) of 3 residents reviewed for pressure ulcers in the sample of 7.Findings include:R2's face sheet documents an admission date of 9/11/2025. Diagnosis include Encounter for other Orthopedic Aftercare, Infection Following a Procedure, Superficial Incisional Surgical Site, Fracture of Lower End of Right Femur, Dementia, Morbid Obesity. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent for transfers and mobility. R2's care plan dated 10/23/2025 documents R2 currently has an alteration to R2's Integumentary System due to Surgical Incision Right Leg. Non-Blanchable area to right/left buttocks and coccyx. Blister to Left Buttock. On 9/25/25: R2 has a stage 1 to her buttocks/coccyx. Educate R2, Power of Attorney, POA or caregiver as to causes of skin break down, skin tear, or pressure ulcer: transfer/positioning or during ambulating.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent resident-to-resident abuse for 1 of 3 residents (R7) reviewed for abuse in the sample of 11.Findings Include: 1. R7's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including major depression disorder, anxiety disorder, chronic pain syndrome, paraplegia, anemia, heart failure, high blood pressure, osteoarthritis and neuropathy. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documents BIMS 14 and no behaviors. R7's Nursing Progress Note, dated 7/29/2025 at 10:08 PM documented, res sustained skin tear to left forearm by another res holding her arm. Skin tear measures 0.4 centimeters (cm) x 0.3 cm. Area cleansed with NS (normal saline), steri strips applied. All parties notified. No documentation of a bruise on R7's left forearm. 2. R8's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and mood disorder. R8'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-20 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to investigate a resident-to-resident abuse for 1 (R7) of 3 residents reviewed for abuse in the sample of 11. Findings include: 1. R7's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including major depression disorder, anxiety disorder, chronic pain syndrome, paraplegia, anemia, heart failure, high blood pressure, osteoarthritis and neuropathy. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documents BIMS 14 and no behaviors. R7's Nursing Progress Note, dated 7/29/2025 at 10:08 PM documented, res sustained skin tear to left forearm by another res holding her arm. Skin tear measures 0.4 centimeters (cm) x 0.3 cm. Area cleansed with NS (normal saline), steri strips applied. All parties notified. No documentation of a bruise on R7's left forearm. 2. R8's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and mood disorder.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to perform safe mechanical lift transfer for 1 of 3 residents (R3) reviewed for accidents in the sample of 6. Findings include: R3's Care Plan, dated 6/13/2025, documents that the resident has potential for falls confusion, deconditioning, Gait/balance problems, incontinence, and poor communication/comprehension, unaware of safety needs. The Care Plan documented Resident had actual falls -6/11/25: Witnessed fall in room out of (full body lift), no injury -1/30/25: Unwitnessed fall in room, no injury. Intervention 6/16/2025 sling with straps for transfers. R3's Incident Report, dated 6/11/2025 at 7:44 PM, documents that Resident transferring per usual from chair to bed by 2 CNAs (Certified Nurse's Aides) using mechanical full lift. During transfer, CNA moved chair out from under resident to position to place in bed. During chair move, resident self-changed position resulting in her rolling through lift straps and onto floor lying on her right side. Resident assessed for injuries; none noted at this time. ROM (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-06-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices, including not wearing a beard net to protect hair from getting into the food, and not covering food items during transportation. This failure has the potential to affect all 38 residents in the facility. Findings include: On 6/12/25 at 8:10 AM, V4, Cook, was seen working in the kitchen, preparing residents breakfast meal with no beard net on while having a full beard and mustache. On 6/12/25 at 9:25 AM, V5, Cook, was seen in the kitchen with a hat on, has a full beard with no beard net on. After V5 was interviewed, he went and got a hairnet and a beard net and put them on. On 6/12/25 at 9:30 AM, R5 stated she mainly eats in the dining room, the food always has a lid on the plate only, but in her room, there is no lid on her drinks or side dishes. R5 stated she does not see the male cooks wearing anything over their beards. On 6/12/25 at 9:35 AM, R2 stated he eats both in his room and in dining room and the main plate of food has a lid on it when 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-01-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to keep daily temperature logs for refrigerators/freezers, wear hairnets covering all hair, dispose of and store food according to policy and hold food temperatures according to policy. This failure has the potential to affect all 38 residents in the facility. Findings include: 1. On 1/22/25 at 8:52 AM, both V3(kitchen manager) and V10(dietary aide) had their hair outside of their hair nets in the kitchen while handling food. On 1/22/25 at 12:00 PM, V10, dietary aide, had hair outside of her net from her ponytail and bangs. V3 told V10 to put all her hair back in the net. V10 put her ponytail in the hair net but her bangs remained outside. V3 did not correct her. V10 picked up her personal cell phone with her left hand's fingers, ungloved, while preparing beverages for the residents, put the cell phone back down on the counter, and then used those same fingers to hold beverages to be served inside the cups with no hand hygiene. V12,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on Interview, Observation, and Record Review, the facility failed to provide heat in the Therapy Department for residents getting therapy for 1 of 1 residents (R4) reviewed for sufficient temperature control in the sample of 9. The Findings Include: On 1/22/25 at 8:43 AM, the Therapy Department is cold and drafty upon entrance. The room has four large windows going from ceiling to approximately two feet off floor, and double doors leading to the outside. The staff was seen wearing a sweatshirt while working with the residents. On 1/22/25 at 8:45 AM, V7, Occupational Therapist, stated It is cold in here. They have been working on our heat. It has been out for about a month now. We try to make sure the residents have a blanket or sweatshirt to stay warm. On 1/22/25 at 10:25 AM, R4 stated he gets therapy at the facility and the room is always cold and you freeze to death. R4 stated he has to bundle up with layers of clothing and then he can't do his therapy correctly. R4's Physician Order, dated 11/5/24, documents OT (Occupational Therapy) clarification for 11/5/24: Skilled OT to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review, the facility failed to secure cigarettes and lighters; failed to reassess resident's smoking risk; and failed to provide appropriate supervision for residents while smoking for 4 of 5 residents (R1, R2, R5, R6)) reviewed for resident safety while smoking in the sample of 9. The Findings Include: 1. R1's Facesheet, dated 1/22/25, documents R1 was originally admitted to the facility on [DATE], with a most recent admission of 3/31/24 with diagnosis of Hydronephrosis, Emphysema, Extended-Spectrum Beta-Lactamases (ESBL), Cirrhosis of Liver, Malnutrition, Peripheral Vascular Disease (PVD), Thrombocythemia, Methicillin-Resistant Staphylococcus Aureus (MRSA), Neuromuscular dysfunction of bladder, Bilateral Above Knee Amputation (AKA), COVID, Arteriosclerotic Heart Disease (ASHD), Hypertension (HTN), Benign Prostatic Hyperplasia (BPH), Depressive Disorder, Anemia, Generalized Anxiety disorder, Falls, and Hepatitis C. R1's Care Plan, dated 11/28/24, documents R1 is 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-16 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to provide a full-time working Director of Nursing (DON) for 18 of 18 days reviewed. This has the ability to affect all 38 residents in the facility. Findings include: On 1/15/2025 at 12:12 PM V1, Administrator, stated that the previous DON resigned and left before date provided. V1 stated that V2, Acting DON, was a floor nurse and accepted the DON position. V1 stated that V2 is not here this morning because she works evenings for the RN coverage. V1 stated that she is in the process of hiring a DON and should start next week. On 1/15/2025 at 3:10 PM V2, Acting DON, stated that she started the position January 1st of 2025. V2 stated that she only works evenings as scheduled. V2 stated that the DON duties that she performs is whatever V1 ask her to. V2 stated that she does not perform any other duties. The Facility provided V2's time report and documented V2 did not work on the following days for December 2024 and January 2025: 12/1, 12/2, 12/6, 12/9, 12/10, 12/14, 12/15, 12/16, 12/20, 12/21, 12/23, 12/24, 12/28, 12/29, 1/1,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-16 · tag F0839 — widespread
    Employ staff that are licensed, certified, or registered in accordance with state laws.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide a licensed Administrator to oversee their Administrator in training, this has the potential to affect all 32 residents living in the facility. Findings Include: On 1/15/2024 at 9:00 AM V1, Administrator, stated that the facility's census was 38. On 1/15/2025 at 12:12 PM V1 stated that she has been at the facility for years. V1 stated that she did Minimum Data Set (MDS) for 3 years and then stepped in as administrator in the last 3 weeks. V1 stated that she started on 12/23 or 12/24. V2 stated that V11, Previous Administrator, had been the administrator for the last year. V2 stated that V11 resigned and left prior to the date of her resignation. V1 stated at that time V12, Infection Control and wound nurse stepped in for 5 days and then quit. V1 stated that she has worked for the last 3 weeks in the administrator position and that last Wednesday she filed for her temporary license. V1 stated that the state of Illinois have all of her stuff and she is waiting on processing. On 1/15/2024 at 3:28 PM V1 stated that 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-16 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 implement their Abuse, Prevention and Prohibition Policy for 2 of 5 (R4, R6) residents, reviewed for misappropriation of resident property, in the sample of 7. Findings Include: 1. R4's admission Record, not dated, documents Major Depressive Disorder, and Essential (Primary) Hypertension. On 1/15/2025 V1, Administrator, provided a daily census that identified R4 as interview able. R4's Minimum Data Set, dated [DATE], documents that R4 has moderate cognitive impairment. On 1/15/2025 at 9:38 AM R4 stated that she had money missing $100. R4 stated that she was in her room counting her money. R4 stated that V14, Certified Nursing Assistant (CNA), was in the room with her and helped her put the money in her drawer. R4 stated that she left the room and when she returned the money was gone. R4 stated that the only person that knew where the money was, was V14. R4 stated that she notified V1 about it. On 1/15/2025 at 12:12 PM V1, Administrator, stated that 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to initiate an investigation of alleged theft for 2 of 5 (R4, R6) residents, reviewed for misappropriation of resident property, in the sample of 7. Findings Include: 1. R4's admission Record, not dated, documents Major Depressive Disorder, and Essential (Primary) Hypertension. On 1/15/2025 V1, Administrator, provided a daily census that identified R4 as interview able. R4's Minimum Data Set, dated [DATE], documents that R4 has moderate cognitive impairment. On 1/15/2025 at 9:38 AM R4 stated that she had money missing $100. R4 stated that she was in her room counting her money. R4 stated that V14, Certified Nursing Assistant (CNA), was in the room with her and helped her put the money in her drawer. R4 stated that she left the room and when she returned the money was gone. R4 stated that the only person that knew where the money was, was V14. R4 stated that she notified V1 about it. On 1/15/2025 at 12:12 PM V1, Administrator, stated that she has not had…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-09-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the Facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness. This has the potential to affect all 42 residents living in the Facility. Findings include: On 9/17/24 at 7:12 AM, in the dry storage area there was a large clear tub with unpackaged, individual tea pods. There was no lid on the tub, leaving the contents open to air. There was a rolling cart with three pitchers of liquid on top. Two of the pitchers contained a clear liquid, and one contained a red liquid. None of the pitchers were labeled or dated. There was a tall rack with bottles of pancake syrup, lemon juice, peanut butter, and white vinegar that were previously opened, but were not dated upon opening. On 9/17/24 at 7:14 AM, in the standing freezer there was a large plastic bag of donuts and a large bag of garlic bread. Both bags had been opened, and the plastic bags were tied in knots, but neither were labeled or dated. On 9/17/24 at 7:16 AM, in the standing refrigerator there was a zip lock bag with brown lettuce…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-20 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to date insulin for 4 of 4 residents (R10, R7, R28 and R196) reviewed for medication storage in the sample of 24. Findings include: 1. Observation on 9/17/2024 at 9:15 AM the 100/300 medication cart showed R10 Novolog insulin vial was not dated. R10's Physician's Order Sheet (POS) dated, 9/2024, documents Novolog insulin inject 4 unit subcutaneously before meals. 2. Observation of the 100/300 medication cart showed R7 Lantus insulin vial was not dated. R7's POS dated, 9/2024, documents Lantus insulin inject 5 units subcutaneously one time a day for diabetes. 3. Observation of the 100/300 medication cart showed R28 Insulin Aspart insulin vial was not dated. R28's POS dated, 9/2024, documents Insulin Aspart inject 5 units subcutaneously before meals for diabetes. 4. Observation of the 100/300 medication cart showed R196 Toujeo Solostar insulin pen was not dated. R196's POS dated, 9/2024, documents Toujeo Solostar inject 22 units subcutaneously two times a day for diabetes. On 9/17/2024 at 9:22 AM V7, Licensed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to to monitor/supervise a resident from wandering into resident rooms at night for 4 of 4 residents (R4, R8, R25, R39) reviewed for resident rights in the sample of 24. Findings include: Grievance Report Form dated 7/28/2024, documents R4 stated another resident (R37) wanders in her room looking for a facility owned remote. Actions/recommendations: he should be monitored more closely. Action taken: resident (R37) will be given a sitter. Grievance Report Form dated 8/25/2024 documents R10 stated another resident (R37) wanders into resident's room in search of a facility owned remote. On 9/19/2024 at 1:55 PM R4, R8, R25 and R39 stated a resident by the name of (nickname) (R37) wanders into their rooms at night and steals the television remote control. All residents stated they have told the facility time and time again about cowboy doing this but nothing stops him. R25 stated if he comes into my room again I'm going to have to hurt him. R4 stated being 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to implement a resident centered behavior care plan on 1 of 13 residents (R36) reviewed for development/implementation of a comprehensive care plan in the sample of 20. Findings include: R36's Face Sheet, undated, documents R36 has a diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder. R36's Minimum Data Set (MDS), dated [DATE], documents R36 has a BIMS (Brief Interview for Mental Status) score of 10, which indicates R36 has moderate cognitive impairment. R36's Care Plan, dated 9/14/24, documents R36 has a behavior problem, depression and dementia with interventions to give anti-anxiety medications ordered by the physician, monitor/document/report to the physician as needed any ongoing signs or symptoms of depression unaltered by the antidepressant medications and to arrange for psychiatric consult to follow up as needed. The care plan fails to document the behaviors that are exhibited by R36 or resident specific…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review the facility to assess and renew whenever necessary psychotropic medications for two of two residents (R19, R21) reviewed for unnecessary medications in the sample of 24. Findings Include: 1.R19's Electronic Health Record Diagnoses section documents R19 has Alzheimer's Disease late onset, Unspecified Dementia, Panic Disorder, MDDR, and Unspecified Psychosis. R19's Minimum Data Set (MDS) dated [DATE] documents R19 is severely cognitively impaired. R19's Physician Order Sheet (POS) dated 8/5/24 documents Alprazolam 1milligram (mg) every 4 hours whenever necessary (PRN). ( this medication was not assessed and reordered after 14 days.) R19's POS dated 8/11/24 documents Xanax 2 mg twice daily and every 6 hours PRN. ( this medications was not assess or reordered in 14 days) R19's Care Plan dated 8/5/24 documents ()R19 has depression, anxiety, psychosis and receives psychotropic medication. will exhibit indicators of depression, anxiety or sad mood less than daily by…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-08 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to administer medications per Physician Orders in 3 of 5 residents (R2, R10, R11) reviewed for medications in the sample of 17. Findings include: 1-R2's Face Sheet documents, R2 was admitted to the facility on [DATE] with diagnoses, including unspecified systolic (congestive) heart failure, essential (primary) hypertension, low back pain, dependence on supplemental oxygen, type 2 diabetes mellitus with diabetic chronic kidney disease, anemia in chronic kidney disease, major depressive disorder, chronic obstructive pulmonary disease (COPD), altered mental status, repeated falls, peripheral vascular disease, hyperlipidemia, and type 2 diabetes mellitus with diabetic neuropathy. R2's Order Summary Report, printed 11/03/23 documents, order for Symbicort Inhalation Aerosol 80-4.5 MCG/ACT, (Microgram Per Actuation), 2 puffs inhaled orally two times a day for COPD. The start date was 08/22/23, and there was no end date. R2's Medication Administration Record,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-03 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 ensure resident menus and appropriate serving sizes were followed in 4 of 4 residents reviewed for therapeutic diets in the sample of 25. Findings include: 1-The Facility's Dietary Order Listing Report printed 9/28/23 documents, R16 has been on a Regular Diet with Mechanical Soft Texture and Nectar Thick Liquid Consistency since 12/29/22. R16's Dietary Card from 9/26/23 Lunch documents, R16 was on a Mechanical Soft Diet with Nectar Thick Liquids. The Facility's Week 1 Tuesday Mechanical Soft Lunch documents, the entrée was ½ c, (cup), Ground BBQ, (Barbecue), Pork Steak with ½ c Creamed Corn. On 9/26/23 at 12:05 PM V9, Cook, used a Number 16 Scoop to place one scoop of Ground BBQ Pork Steak and one scoop of Creamed Corn on R16's plate. V9 stated she did not know the scoop number or the portion size. 2-The Facility's Dietary Order Listing Report printed, 9/28/23 does not list R9 as having a diet ordered. R9's Dietary Card from 9/26/23 Lunch documents, R9 was on a Mechanical Soft Diet. The Facility's Week 1…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the Facility failed to ensure residents received nutritional supplements and proper portion sizes in 1 of 4 residents reviewed for nutritional status in the sample of 25. This failure resulted in R1 losing significant weight of 12% loss over three months. Findings include: R1's Face Sheet documents R1 has diagnoses including cerebral palsy, dependence on wheelchair, gastro-esophageal reflux disease (GERD) without esophagitis, constipation, vitamin B12 deficiency anemia due to intrinsic factor deficiency, anemia, hypothyroidism, oropharyngeal phase dysphagia (difficulty swallowing), age-related osteoporosis without current pathological fracture, and unspecified intellectual disabilities. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was severely cognitively impaired, required total dependence with two or more-person physical assistance, and required total dependence with one-person physical assistance for eating. R1's Care Plan documents, (R1) has…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-03 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to reconcile controlled medications to enable an accurate accounting of controlled medications in a timely manner for 1 of 1 resident in the sample of 25. R2's Face sheet documents admission date of 4/24/2023. Diagnosis includes Chronic Obstructive Pulmonary Disease, Vitamin D deficiency, Insomnia. R2's Minimum Data Set, MDS, documents R2 has no cognitive deficits and is independent with Activities of Daily Living, ADLs. R2's Care Plan dated 8/14/2023 documents R2 has pain. Interventions include Anticipate R2's need for pain relief. R2's Order Sheet dated 6/8/2023 documents Tramadol HCL 50mg. Give 1 tablet by mouth every 8 hours as needed for back pain until 6/15/2023. Facility Incident Report dated 6/12/2023 documents, June 11th, 2023, at approximately 10:00PM, V2, Director of Nursing, DON, was notified by V14, Licensed Practical Nurse, LPN, that R2's card of 18 Tramadol was missing. June 12th all Nurse Managers looked for medications and medication could not be accounted for. Mascoutah Police notified 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

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

Fines & penalties

$129,084 in federal fines across 3 penalties. 1 Medicare payment denial on record.

  • $44,775 — penalty dated 2025-08-20
  • $56,023 — penalty dated 2025-05-20
  • $28,286 — penalty dated 2023-10-03
  • Medicare payment denial — starting 2023-10-27 for 26 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 JENMAX GROUP — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.0≈ chain avg
Health inspection 2 of 51.9+0.1 vs chain
Staffing 1 of 51.0≈ chain avg
Quality measures 2 of 52.9-0.9 vs chain
The other 6 homes this chain runs (chain average 1.0★, 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 / managerTypeRoleShareSince
BSF FAMILY HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF15%since 04/01/2025
BSF 2025 FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST7%since 04/01/2025
COM FAMILY TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF12%since 04/01/2025
FRIEDMAN, BENJAMINIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNFsince 04/01/2025
MILLMAN, CHAIMIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; TRUSTEE OF THE SNF; ADP OF THE SNFsince 04/01/2025
ETN FAMILY HOLDINGS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
TLCO HOLDINGS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
ERBLICH, AVRAHAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
JACKSON, WARRENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
MATHEW, STANLEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
PLEW, ANDREAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
SHEPS, BORUCHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
SNYDER, NICOLEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2025
E NEWHOUSE FAMILY TRUSTOrganizationADP OF THE SNFsince 04/01/2025
T NEWHOUSE FAMILY TRUSTOrganizationADP OF THE SNFsince 04/01/2025
TLM FAMILY TRUSTOrganizationADP OF THE SNFsince 04/01/2025

CMS files one row per role, so the 33 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

8 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.

$4.3M
Net patient revenuemost recent cost report
+7.4%
Operating marginrevenue minus expenses
$111K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 55%Medicare 8%Other / private 37%

This home reported $111K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$258per resident / day
operating cost
$7,858per month
≈ monthly operating cost
$279per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145518. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-19, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

What to do next