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Nexus at Mascoutah

901 North Tenth Street, Mascoutah, IL 62258 · For profit - Partnership · 55 certified beds · (618) 566-2183 Medicare & Medicaid certified

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Flagged for abuse7 actual-harm citations$73,886 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602, F0610) — most recent Jul 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 7 actual-harm citations
  • a high number of inspection citations overall (41) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $73,886 in federal fines (most recent 2025-07-07)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (78%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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 4 of 5

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

Location & what’s nearby

Hospital
★★★★ 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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 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 improved from 1 to 2 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 rating2★
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 increased9.0%13.4%15.4%better
Long-stay residents who lose too much weight8.3%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms98.2%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.6%3.1%3.3%better
Long-stay residents whose ability to walk worsened5.7%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication30.1%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers5.1%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control29.8%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table4.7%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.3%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine100.0%63.1%79.4%better
Short-stay residents rehospitalized after admission35.8%26.1%22.6%worse
Short-stay residents with an outpatient ER visit15.4%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.492.021.67worse
Long-stay outpatient ER visits per 1,000 resident days2.822.221.80worse

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.

48.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.3%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
61.9%U.S. median 56.6%
Met the expected recovery
0.37U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.12hours / resident / day
Speech therapy

Met the expected recovery: 61.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.37 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 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

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 SNF48.3%CMS range 33.7–62.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 7.4–17.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge61.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge61.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%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 worsened0.0%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 hospitalization7.4%CMS range 4.5–14.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 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

0.52
RN hours/ resident / day
1.00
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.68
Total nurse hours/ resident / day
0.32
RN hoursweekends
77.6%
Total nursing turnover
71.4%
RN turnover

How full it usually is: this home is certified for 55 beds and averages 47.8 residents a day — about 87% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.24 hrs/resident/day on weekends vs 3.85 on weekdays — 16% thinner on weekends. RN hours go from 0.60 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 78% 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

12
deficiencies at the latest standard inspection (2024-08-12)
3
at the previous standard inspection (2023-10-24)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

41 citations, most serious first. The 17 most serious are shown; the remaining 24 are one tap away and print in full.

  • Actual harm · Gcited before2025-08-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to properly clean an indwelling urinary catheter, failed to complete and document indwelling catheter care as ordered, failed to verify an indwelling urinary catheter flush order, failed to monitor intake and output as ordered, and failed to ensure a resident's indwelling was properly positioned and covered for 3 of 3 residents (R1, R2, R5) reviewed for indwelling urinary catheters in the sample of 11. These failures caused R2 to experience increased pain and sepsis secondary to developing a catheter associated urinary tract infection. Findings Include:1. R2's admission Record document, print date of 8/18/25, documented R2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses including Wernicke's encephalopathy, type 2 diabetes mellitus, chronic gout, insomnia, alcohol abuse, major depressive disorder, polyneuropathy, hypertension, and obstructive and reflux uropathy.R2's MDS, dated [DATE], documented R2 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-07-07 · 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 observation, interview, and record review, the facility failed to provide resident care in a timely manner to promote resident's dignity for 3 of 5 residents (R1, R2, and R5) reviewed for dignity in a sample of 5. This failure resulted in R2 having feelings of frustration due to soiling herself and being left on a bedpan for 29 minutes and reporting pain related to this. Findings include: 1. R2's Face sheet documented she was admitted to the facility on [DATE] with diagnoses of, in part, congenital subaortic stenosis, type two diabetes mellitus, and acquired absence of bilateral legs below the knee. R2's Minimum Data Set (MDS) dated [DATE], documented she was cognitively intact and dependent on staff for toileting hygiene assistance. R2's Care Plan dated 6/27/25 documented she was at risk for skin complications related to immobility. R2's Care Plan dated 6/20/25 documented she has an alteration in comfort advanced disease process, chronic physical or psychological disability circulatory,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-04-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure an environment free from abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. This Failure caused R1 to be fearful of R2 and causes her to have trouble sleeping. Findings include: R1's Face Sheet documents, R1 was admitted to the facility on [DATE] with diagnoses, including type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, osteoarthritis, and muscle weakness and atrophy. R1's Minimum Data Set, (MDS), dated [DATE] documented, R1 was independent with cognitive skills for daily decision making with short term memory intact. The MDS documented R1 required substantial/maximal assistance with bed mobility and transfer and ambulated with manual wheelchair. R1's Undated Care Plan, documents, R1 is at risk for abuse and neglect. R2's Face Sheet, documents, R2 was admitted to the facility on [DATE] with diagnoses, including encephalopathy, multiple sclerosis, difficulty…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-01-12 · 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 The Facility failed to ensure a bruise of unknown origin was investigated and the appropriate corrective actions were initiated for 1 of 3 residents (R2) reviewed for injuries in the sample of 9. Findings include: R2's Physician Order Sheet for January 2024 documents a diagnosis of: Abnormalities of gait and mobility, lack of coordination, displaced supracondylar fracture without intercondylar extension of lower end of left femur, subsequent encounter for closed fracture with routine healing, abnormal weight gain, cognitive communication deficit, major depression, paraplegia, idiopathic peripheral autonomic neuropathy, anemia, acute infraction of spinal cord, pressure ulcer of sacral region, and altered mental status. R2's Minimum Data Set (MDS) documents she is moderately impaired for cognition. Bed mobility R2 was scored as 3/3 (extensive assist of two plus staff). Transfer 4/3, (total dependence on staff of two plus staff members). R2 does not walk, for toilet use she was scored a 4/3, and for personal…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-01-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the Facility failed to ensure a safe transfer for 1 of 3 residents (R2) reviewed for transfers in the sample of 9. This failure resulted in R2 being picked up by staff after a fall and transferred to a chair and sent out to the hospital later where she sustained a tibia spiral fracture. Findings include: R2's Physician Order Sheet for January 2024 documents a diagnosis of : Chronic obstructive pulmonary disease, abnormalities of gait and mobility, lack of coordination, displaced supracondylar fracture without intercondylar extension of lower end of left femur, subsequent encounter for closed fracture with routine healing, abnormal weight gain, cognitive communication deficit, major depression, reflex neuropathic bladder, paraplegia, idiopathic peripheral autonomic neuropathy, anemia, acute infraction of spinal cord, pressure ulcer of sacral region, and altered mental status. R2's Minimum Data Set (MDS) documents she is moderately impaired for cognition. Bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-10-24 · 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 abuse for 4 of 5 residents (R4, R13, R38, R102) reviewed for abuse in the sample of 43. This failure resulted R102 who is demented being fondled by R38 in the dining room and a reasonable person would not want to be sexually fondled/abused. Findings include: 1.R38's Face Sheet, with print date of 10/192/3, documents R38 has diagnoses of personal history of traumatic brain injury, major depressive disorder, schizoaffective disorder, bipolar type, and altered mental status. R38's Care Plan, dated 9/11/23, documents Resident's memory is impaired, and resident has difficulty with decision-making, insight, logic, planning, and organization of the thoughts. The Care Plan Interventions documented Provide clear explanations regarding expectations and procedures prior to providing care. R38's Care Plan documents Resident has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2022-09-02 · 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 conduct ongoing assessment and monitoring of a resident with significant weight loss for 1 of 5 residents (R12)reviewed for nutrition in the sample of 26. This failure resulted in continued weight loss for the resident. Findings include: On 8/31/22 at 1:14 PM, R12 was sitting in a geriatric chair at a table in the dining room and stated, I've been here before. R12 was feeding herself pureed spaghetti, mixed vegetables, ice cream, and cake fortified with powdered milk. R12's Face Sheet documents R12 was admitted to the facility on [DATE] and has diagnoses including unspecified severe protein calorie malnutrition, dysphagia (difficulty swallowing), abnormal weight loss, unspecified dementia without behavioral disturbance, major depressive disorder, and gastroesophageal reflux disease without esophagitis. R12's Minimum Data Sheet (MDS) dated [DATE] documents R12 has significant cognitive impairment and requires extensive 2+ person assistance…

    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 before2026-07-02 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent misappropriation of resident medications in 2 of 7 residents (R1, R2) reviewed for abuse in the sample of 7. This past non-compliance occurred on 6/2/26 with a correction date of 6/2/26. Findings Include:1) R1's Face Sheet, undated, documents R1, in part, has the following diagnosis: Osteomyelitis, Malignant Neoplasm of the Endometrium, Pain in Bilateral Feet, Neuropathy, and OA (Osteoarthritis). R1's MDS (Minimum Data Set), dated 5/27/26, documents R1 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R1 is cognitively intact. R1's Care Plan, dated 5/4/23, documents R1 is at risk for abuse. R1's Progress Note, dated 6/2/26 9:00 PM, documents the following: Resident notified by administrator (she is her own responsible party) of an ongoing investigation regarding a potential medication diversion incident involving facility staff. Resident was informed that a review of medication administration records is being conducted 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2025-08-25 · 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 record review and interview, the facility failed to verify and implement a consultant physician's instructions, failed to follow hospital discharge orders for normal saline indwelling urinary catheter flushes, and failed to document a resident's response to antibiotics for 1 of 3 residents (R2) reviewed for quality of care in the sample of 11.Findings include:R2's admission Record document, print date of 8/18/25, documented R2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses including Wernicke's encephalopathy, type 2 diabetes mellitus, chronic gout, insomnia, alcohol abuse, major depressive disorder, polyneuropathy, hypertension, and obstructive and reflux uropathy.R2's MDS (Minimum Data Set), dated 7/14/25, documented R2 was severely cognitively impaired, dependent on staff for toileting and hygiene needs, and had an indwelling urinary catheter.R2's care plan, initiation date of 6/30/25, documented R2 required use of an indwelling catheter related to obstructive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the facilities policy and don proper PPE (personal protective equipment) while providing care for 2 of 3 (R1, R5) residents reviewed for indwelling urinary catheter in the sample of 11. 1.R1's admission Record, print date of 8/18/25, documented R1 has diagnoses including rheumatoid arthritis, malnutrition, chronic fatigue, heart failure, altered mental status, neuromuscular dysfunction of bladder, cognitive communication deficit, hypertension, and acquired absence of right shoulder. R1's MDS (Minimum Data Set), dated 7/11/25, documented R1 is moderately cognitively impaired.R1's care plan, undated, documented R1 has an (indwelling urinary catheter) related to neurogenic bladder and is at risk of infection. R1's care plan also documented R1 requires enhanced barrier precautions with interventions including staff to wear gown and gloves when performing ADL'S (activities of daily living). On 8/18/25 at 8:38 AM R1 was observed in bed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-07-24 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure clean linen carts were kept covered and protected from contaminates. This failure has to potential to affect all 51 residents who reside at the facility. Findings include:On 07/21/25 at 10:15 AM, in the shower room/bathroom on the 100-hallway, the clean linen cart was sitting next to the commode in the shower room and the clean linen cart did not have the front cover pulled down to cover all the clean linen and thus the clean linen was exposed to different contaminates. In the shower room there was also dirty linen barrels as well as the clean linen.On 07/22/25 at 10:40 AM, in the women's shower room on the 200-hallway, the clean linen cart was sitting up against the wall with the cover thrown up over the top of the cart and all the linen on the cart was exposed. There were two barrels containing dirty linen on wheels sitting about three feet away from the clean linen.On 07/22/25 at 10:45 AM, in the men's shower room on the 200-hallway there was a clean linen cart sitting up against the wall with the…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-24 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to address residents needs by answering call lights in a timely manner for 4 of 5 residents (R1, R3, R4, and R6) reviewed for call lights in a sample of 9. Findings include:1. R1's Face Sheet, with original admission date of 01/15/18, documented R1 has diagnoses of but not limited to multiple sclerosis, schizoaffective disorder, and bipolar disorder. R1's Minimum Data Set (MDS), dated [DATE], documented R1 is moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 10 out of 15, she is dependent on staff for most of her activities of daily living (ADL), and she is always incontinent of bowel and bladder.On 07/22/25 at 9:55 AM, R1 said it can sometimes take the Certified Nursing Assistants (CNA) a little while to answer her call light.2. R3's Face Sheet, admission date of 06/20/25, documented R3 has diagnoses of but not limited to congenital subaortic stenosis, type II diabetes mellitus, schizophrenia, and hypertension (HTN). R3'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-08 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent an employee from misappropriating narcotic pain medication for 2 of 3 residents (R2, R3) reviewed for misappropriation of property in a sample of 3. Findings include: 1. R2's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnosis of pain and GERD. R2's Undated Care Plan, documents chronic pain related to GERD and chronic knee pain. R2's Physician's Order Sheet (POS) dated 4/2025 and 5/2025 documents a physician's order, start date of 7/14/2024, hydrocodone-acetaminophen 5-325 milligrams (mg) give 2 tablets by mouth every 4 hours as needed for pain. R2's Minimum Data Set (MDS) dated [DATE] documents resident is cognitively impaired and has occasional pain. R2's Controlled Drug Received Record/Disposition Form, received from the pharmacy on 7/26/2024 documents V4, Licensed Practical Nurse, LPN, signed off she administered hydrocodone 5-325 mg to R2 on 4/17/2025, 4/22/2025, 4/27/2025,…

    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 before2025-05-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure progressive fall interventions were in place and staff were aware of these interventions for 1 of 4 residents (R5) reviewed for falls in the sample of 7. Findings include: R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, cerebral infarction, hypotension, dementia and abnormalities of gait and mobility. R5's Minimum Data Set, dated [DATE] documented R5 was severely cognitively impaired, used wheelchair and required partial assistance with walking. R5's Care Plan documents R5 is at risk for falls. R5's Fall Risk assessment dated [DATE] documented R5 was at high risk for falls. R5's Fall Investigation dated 10/9/24 documents R5 tripped while ambulating and fell. There was no injury. R5's Care Plan Update on 10/9/24 documents staff were educated to ensure R5 is wearing grippy socks at all times when out of bed. R5's Fall Investigation dated 4/13/25 documents R5 was found on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-28 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure resident rights were respected regarding a social media post for 1 (R2) of 3 residents in a sample of 3. R2's Undated Face Sheet, documents R2 was initially admitted to the facility on [DATE] with diagnoses including pain, generalized anxiety disorder and mild cognitive impairment. R2's Quarterly Minimum Data Set (MDS) dated [DATE] documents resident is alert. On 3/28/2025 at 9:32 AM V1, Administrator stated she recently received an anonymous call on Monday morning 3/24/2025, the call ID was blocked, and the caller reported that (V5), LPN (Licensed Practical Nurse) posted on social media talking about a resident and the anonymous caller sent screen shots of the social media post to V1. She stated no residents or facility name was listed in the post. V1 forwarded the social media screen shots to human resources, and they stated no issues because no residents were named and no facility was named. V5's Social Media Post dated 9/10/2024,…

    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 before2024-10-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure progressive interventions were being implemented for 1 of 3 residents (R2) reviewed for falls in the sample of 6. Findings include: R2's Physician Order Sheet for October 2024 documents a diagnosis of encephalopathy, chronic obstructive pulmonary disease (COPD), hemiplegia affecting left non dominant side, cerebral infarction, diabetes, weakness, pain in right hip, unspecified convulsions, schizoaffective disorder, unspecified dementia, and unspecified psychosis. R2's Minimum Data Set, (MDS) dated [DATE] documents R2 was moderately impaired for cognitive impairment for decision making of activities of daily living. R2 requires use of a wheelchair. R2 requires moderate assistance with showering and personal hygiene. He requires set up for eating, oral hygiene, upper and lower body dressing and taking off and applying footwear. R2 also has a (urinary) catheter and is frequently incontinent of bowel. R2's Fall risk evaluation dated 8/25/2024 at 6:07…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure residents were free from abuse for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 3. Findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, cerebral infarction, and unspecified dementia with agitation. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was moderately cognitively impaired, required partial assistance with bed mobility, was dependent with transfer, and ambulated via wheelchair. R1's Undated Care Plan documents R1 has potential to be verbally aggressive to other residents and staff related to poor impulse control. The Care Plan update on 11/26/22 documents, Pulled female resident's hair in dining room. The Care Plan update on 8/26/24 documents, Hit female resident in the mouth. R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including muscle weakness, major depressive disorder, and 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 24 citations
  • Potential for harm · Fcited before2024-08-12 · 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 interview, observation and record review, the facility failed to perform proper hand hygiene and/or the wearing of gloves while plating food and failed to check and maintain the temperatures of the food, including all diets (regular diets, special diets, and pureed foods), prior to serving the residents to prevent contamination and foodborne illness. This failure has the potential to affect all 50 residents living in the facility. The findings include: On 8/5/24 at 12:10 PM, Upon walking into kitchen, V8 (Cook) was already starting to plate food with no gloves on. When asked if temperature checks were done, V8 stated I checked them when I took them off the stove. When asked to check temperatures: Turkey was at 160 degrees Farenheight (F.), Gravy at 163 degrees F., Mashed potatoes at 160 degrees F., [NAME] beans at 192 degrees F., Cream corn at 135 degrees F., and Mechanical Soft turkey was reading 120 degrees F. The Mechanical Soft food was put in the microwave by V7 (Dietary Manager-DM), for 15 seconds, he rechecked the temperature which was reading 135 degrees F. The…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-12 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to promote a pest free environment by not removing flies from resident's rooms for 6 out of 6 residents, (R6, R103, R13, R46, R22, R11), reviewed for pest control in a sample of 41. Findings include: On 8/5/24 at 9:30 AM, R6 has flies her in room, R6 stated the flies are bad here. On 8/5/24 at 9:35 AM, R103 had flies in his room; R103 stated the flies are a [NAME] to him and have been bad. On 8/5/24 at 9:58 AM, R46 had flies in her room and there is a fly swatter on her bedside table. On 8/5/24 at 10:02 AM, R13 had flies in her room and a fly swatter. R13 stated the flies are bad here and complained about them but nothing has been done. On 8/5/24 at 10:15 AM, R11 has flies in her room. R11 stated the flies have been horrible for 3-4 months now and because she has to use a bedside commode, the flies get worse. R11 stated she has complained about the flies, but nothing has been done. On 8/6/24 at 10:30 AM, R22 has flies in her room. R22…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-12 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to properly administer medications to residents, including interpreting prescriber's order and ensuring the resident receives their medications, to meet their needs for 4 of 5 residents (R22, R33, R38, R103) reviewed for medication administration in the sample of 41. Findings include: 1. On [DATE] at 8:35 AM, V10, Registered Nurse (RN) was administering medications to R103. V10 placed a Multi-Vitamin (MVI) in a medicine cup to give to R103. Upon examination of the bottle, the expiration date was 11/2023. V10 was advised of the expiration date and removed the MVI from the cup. V10 went to the other medication cart and the MVI bottle in that cart was also expired. V10 stated that V2, Director of Nursing (DON), will be going to the local pharmacy to get some. V10 placed a Lisinopril 2.5 MG (milligram) tablet in a medicine cup to give to R103. The physician's order documented 5 MG, when V10 was advised of the physician order, V10 noticed it was incorrect, and…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-12 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove expired medication from the medication room refrigerator, restock the medication shelf, and medication cart. Findings include: On [DATE] 10:05 AM Medication Storeroom refrigerator was inspected, and the following was found. 1. R47 was observed to have a COVID-19 (Spikevax injection) 50/0.5ml (milliliters) one time dose with an expiration date of [DATE]. 2. There were two Forteo (Teroparatide) insulin pens inject 0.08ml (20mcg [micrograms] total) under the skin daily labeled with R22's name and the label also documented discard after 28 days after initial use. One had an expiration date of [DATE] and the other had an expiration date of [DATE]. A foil package in the refrigerator was also observed and contained the following medications: 3. Two unopened vials of Novolin R 100 insulin units/ml with expiration dates of [DATE]. 4. One unopened vial of Humulin N insulin 100 units/ml with an expiration date of 11/2023. 5. One unopened vial…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-12 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 80 square feet of floor space per resident bed for 9 of 50 residents (R5, R11, R15, R19, R20, R22, R32, R33, and R103) reviewed for room size in the sample of 41. Findings include: On 08/12/24 at 10:19 AM V1 (Administrator) stated there has been no changes of the measurements and accuracy of the facility's waivered resident room numbers and certifications. V1 stated there were 5 rooms on the 100 hall and all rooms were Medicare and Medicaid certified and provide 77.5 square feet per resident per bed. R5, R11, R15, R19, R20, R22, R32, R33, and R103's rooms were measured on the 100 hallway and each room measured was less than 80 square feet per resident. Observations made throughout the survey from 08/05/24 through 08/12/24 demonstrated no concerns or complaints vocalized by residents in relation to waivered room size. On 08/06/24 at 11:00 AM, during the resident group meeting no residents voiced any complaints or concerns regarding room size. The facility provided a list of residents affected by the…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-12 · 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, observation, and record review the facility failed to promote respect and dignity in an environment that promotes maintenance by not providing timely removal of urine and feces from a resident's bedside commode for 1 of 1 resident (R11) reviewed for dignity in a sample of 41. Findings include: R11 was admitted to the facility on [DATE] with diagnosis of, in part, anxiety and major depressive disorders, fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing and lack of coordination. R11's Minimum Data Set (MDS) dated [DATE] documents R11 as being moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 9. During this investigation, R11 was alert and oriented to person, place and time. R11's MDS further documents R11 requires partial/moderate assistance for: toilet transfer: The ability to get on and off a toilet or commode and toileting hygiene: The ability to maintain perineal hygiene, adjust clothes…

    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 · D2024-08-12 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) of Non-coverage for 1 of 3 (R6) reviewed for Beneficiary Notice in the sample of 41. Findings include: R6's admission Record documented an admission date to the facility of 12/05/2023. Diagnoses listed on this same document include, but are not limited to: Osteomyelitis of Vertebra, Morbid (Severe) Obesity due to excess calories, Weakness, Difficulty Walking, not elsewhere classified . The document titled Beneficiary Notice - Residents discharged Within the Last Six Months noted R6 remained in the facility but listed a service discharge date of 3/3/24. Review of R6's Electronic Health Record (EHR) does not note a SNF ABN form associated with the 3/3/24 service discharge date . R6 was interviewed on 8/12/24 at 9:10 am and asked if she received a SNF ABN regarding her 3/3/24 discharge from services and she stated that she does not remember. On 8/6/24 at 9:33 AM, V1 (Administrator) stated that the facility did not issue a SNF ABN to R6 with her 3/3/24…

    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 · D2024-08-12 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident in writing of the involuntary discharge and opportunity for appeal for 1 of 1 residents (R51) and no written notification was sent to the family for 1 of 1 residents (R9) reviewed for discharge in a sample of 41. Findings include: 1. R51's undated admission record documents an admission date of 5/27/2024. R51's Progress note, dated 5/27/2024 at 6:39 pm, documented Resident arrived at facility via EMS (emergency medical services). A&O (alert and oriented) x4 and able to let needs be known to staff. R51 is documented to be continent of bowel and bladder. No c/o (complaints of) pain or discomfort. Respiration even and non-labored. BS (bowel sounds) active. Resident oriented to room and use of call light. R51's Progress note dated 5/28/24 at 8:35 am documented Patient was in 08/06/24 01:54 PM pain and rated it a 14 on a scale of 0-10. When speaking with the patient and her husband, they requested to be sent back to the hospital. Patient…

    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 · D2024-08-12 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident in writing of the voluntary discharge and bed hold notice for 1 of 1 residents (R51) reviewed for discharge in a sample of 41 On 08/06/24 02:28 PM, admission profile undated documents admission on [DATE]. R51's Progress note, dated 5/27/2024 at 6:39 pm, documented Resident arrived at facility via EMS (Emergency Medical Services). A&O (alert and oriented) x4 and able to let needs be known to staff. Resident cont (continent) of b&b (bowel and bladder). No c/o (complaints of) pain or discomfort. Respiration even and non-labored. BS (bowel sounds) active. Resident oriented to room and use of call light. R51's Progress note dated 5/28/24 at 8:35 am documented Patient was in 08/06/24 01:54 PM pain and rated it a 14 on a scale of 0-10. When speaking with the patient and her husband, they requested to be sent back to the hospital. Patient left facility via EMS with husband to local hospital, ER (emergency room) notified. Patient was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow nurse practitioner recommendations in a timely manner for 1 of 41 (R35) residents reviewed for quality of care in a sample size of 41. Findings include: R35's Face Sheet, print date of 08/12/24, documented R35 has diagnoses of but not limited to unspecified open wound, left lower leg, Type II Diabetes Mellitus, paraplegia, complete, and polyneuropathy. R35's Minimum Data Set (MDS), dated [DATE], documented R35 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he is dependent on staff for bed mobility, transfers, and most of his dressing. R35's Care plan, admission date of 01/19/24, documented SKIN: At risk for skin complications related to (r/t) immobility. R35's Physician's Orders, dated 07/12/24, documented referral to vascular surgeon, peripheral artery disease, delayed wound healing. R35's Physician's Orders, dated 07/27/24 documented an order was placed for R35 to get a magnetic resonance imaging (MRI)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record, review, the facility failed to use appropriate safety procedures to assure resident safety during transfer for 1 of 3 (R5) reviewed for resident safety in the sample of 41. The findings include: R5's admission Record, undated, documents R5 was admitted to the facility on [DATE] with diagnosis of Dementia, Cerebral Infarction, Traumatic Brain Injury (TBI), Dysphagia, Falls, Major depressive disorder, COVID, Hypertension, Osteoarthritis, and Convulsions. R5's Care Plan, dated 6/25/24, documents R5 has a potential for Activities of Daily Living (ADL) self-care performance deficit related to Diagnosis TBI, seizures, osteoarthritis. Requires supervision and set-up with most ADLs at this time. Interventions: R5 requires supervision assistance from one staff for toileting. It continues; R5 is risk for falls related to history of falls, Bilateral Lower Extremities (BLE) weakness, confusion, Diagnosis TBI, history of Cerebrovascular Accident (CVA)/Trans Ischemic Attack (TIA).…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide complete incontinent care for 1 of 5 residents (R5) reviewed for incontinence care in the sample of 41. The findings include: R5's admission Record, undated, documents R5 was admitted to the facility on [DATE] with diagnosis of Dementia, Cerebral Infarction, Traumatic Brain Injury (TBI), Dysphagia, Falls, Major depressive disorder, COVID, Hypertension, Osteoarthritis, and Convulsions. R5's Care Plan, dated 6/25/24, documents R5 has a potential for Activities of Daily Living (ADL) self-care performance deficit related to Diagnosis TBI, seizures, osteoarthritis. Requires supervision and set-up with most ADLs at this time. Interventions: R5 requires supervision assistance from one staff for toileting. R5's Minimum Data Set (MDS), dated [DATE], documents R5 has a severe cognitive impairment and is dependent on staff for toileting, bathing, personal hygiene, and transfers including sit to stand and toilet transfers. R5 is always…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to report allegations of abuse in 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. Findings include: R2's Face Sheet documents, R2 was admitted to the facility on [DATE] with diagnoses including encephalopathy, multiple sclerosis, difficulty walking, lack of coordination, weakness, insomnia, bipolar disorder, schizoaffective disorder, and major depressive disorder. R2's Minimum Data Set, (MDS), dated , [DATE], documented, R2 was moderately cognitively impaired with inattention and disorganized thinking, used wheelchair, and required partial/moderate assistance with bed mobility and transfer. R2's Undated, Care Plan does not address risk for abuse or identified sexual behaviors. On [DATE] at 9:30AM, V10, Sexual Assault Nurse Examiner, (SANE), Team Lead from Local Hospital, stated, (R2) did pop positive on the pregnancy test, both urine and blood. The blood levels are low, so that can mean other things, and the Doctor is pretty confident 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 before2024-04-26 · 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 an allegation of sexual abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings include: R1's Face Sheet documents, R1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, anxiety, depression, osteoarthritis, and muscle weakness and atrophy. R1's Minimum Data Set, (MDS), dated [DATE] documented, R1 was independent with cognitive skills for daily decision making and short-term memory was intact. The MDS documented, R1 required substantial/maximal assistance with bed mobility and transfer and ambulated with manual wheelchair/scooter. R1's Undated, Care Plan, documents, R1 is at risk for abuse and neglect. R2's Face Sheet documents, R2 was admitted to the facility on [DATE] with diagnoses including encephalopathy, multiple sclerosis, lack of coordination, insomnia, bipolar disorder, schizoaffective disorder, and major…

    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 before2024-03-29 · 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 provide ice water to 2 (R2 and R3) of 3 residents, at risk for dehydration, in the sample of 9. Findings Include: R2's Face Sheet documents an admission date of 1/26/2024. Diagnosis include Type 2 Diabetes, Diabetic Retinopathy, Respiratory Failure with Hypoxia, Obesity, Schizophrenia. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent on staff for toileting, showering, dressing, uses wheelchair. Is always incontinent of bowel and bladder. R2's Care Plan dated 1/26/2024 documents Hydration: R2 is At risk for alteration in fluid volume related to history of dehydration. Interventions include: Encourage fluid intake. Keep fresh water in reach of R2. On 3/28/2024 at 8:30AM, R2's water pitcher was empty. R3's Face Sheet documents an admission date of 1/2/2023. Diagnosis include Protein-Calorie Malnutrition, Abnormal gait, Lack of Coordination, Weakness. R3's MDS dated [DATE] documents R3…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents were not being physically abused for 1 of 3 residents (R1) reviewed for abuse in the sample of 9. Findings include: R1's Physician Order Sheets for January 2024 documents a diagnosis of Respiratory failure, type 2 DM, metabolic encephalopathy, acute kidney failure, Schizoaffective, Bipolar type, HTN herpes viral encephalitis, MDDR, seizures, Falls, spondylosis, pneumomediastinum, CKD, HLD, cerebral ischemia, and traumatic brain injury. R1's Care Plan: document (R1) is at risk for psychosocial well-being related allegations of abuse. R1 also, was documented, as having a history of being placed on one on one supervison. R1's Minimum Data Set (MDS) dated [DATE] document R1 was cognitively intact for decision making. R1's Nurse's Notes dated 12/7/2023 at 12:21 AM, documents, Note Text: Resident was removed from one-on-one observation yesterday 12/06/2023 at 1:30 pm and moved to 30-minute checks. The resident seemed very restless all evening…

    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 before2023-10-24 · 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 and prepared in a manner which prevents potential contamination. This has the potential to affect all 53 residents living in the facility. Findings include: On 10/17/223 at 8:32 AM, in the refrigerator there was a large box containing approximately 12 cucumbers. The cucumbers were soft and mushy in appearance covered with a greenish fuzzy growth growing on top of the cucumbers. On 10/17/2023 at 8:39 AM, in the refrigerator there was a half of watermelon covered with foil with the use by date of 10/9/2023. On 10/17/2023 at 8:46 AM, the fryer had two baskets hanging from the fryer. The oil inside the fryer needs change, there are fried particles in the grease, the grease is discolored, and the color and clarity were off. There were darkened brown stains, sticky oil stains on the baskets, and the metal portion of the fryer. On 10/17/2023 at 8:52 AM, V4, Dietary Manage stated the watermelon and cucumbers should have been thrown out. I would expect food to be inspected and thrown out when it…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-08-31 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure that administration implemented hot weather plan/policy during a week of excessive heat to ensure residents were residing in a comfortable environment. This has the potential to affect all 54 residents living in the facility. Findings include: During this survey on 8/25/2023 at 3:01 PM, V1, Administrator did not have a current and up to date licensee displayed in her office. On 8/31/2023 at 9:22 AM, V1 stated, I applied for my temporary licensee back in January and then I was notified in May that my papers were not filled out correctly and I needed a physician signature on my application. I got the signature and sent it back into the state and they cashed my check, but I still have not received my temporary licensee. I am the only Administrator for this facility and there is nobody overseeing me. Police Report Incident occurred on 8/24/2023 at 6:43 PM, On 8/24/2023 at approximately 6:43 PM, Hours, I (V11, Police Officer) was contacted by dispatch…

    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 · F2023-08-31 · tag F0835 — failed to run the facility competently — widespread
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the Facility failed to ensure there was a licensed administrator working in the facility and the administrator was acting in a manner to ensure proper building temperatures were being maintained. This has the potential to affect all 54 residents living in the facility. Findings include: During this survey on 8/25/2023 at 3:01 PM, V1, Administrator did not have a current and up to date licensee displayed in her office. On 8/31/2023 at 9:22 AM, V1 stated, I applied for my temporary licensee back in January and then I was notified in May that my papers were not filled out correctly and I needed a physician signature on my application. I got the signature and sent it back into the state and they cashed my check, but I still have not received my temporary licensee. I am the only Administrator for this facility and there is nobody overseeing me. Police Report Incident occurred on 8/24/2023 at 6:43 PM, On 8/24/2023 at approximately 6:43 PM, Hours, I (V11, Police Officer) was contacted by dispatch in reference to call for information. I made…

    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 · Fcited before2022-09-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner which prevents potential contamination. This has the potential to affect all 48 residents living in the facility. Findings include: On 8/30/22 at 8:22 AM, V5, Dietary Aid, and V6, Cook, were preparing breakfast trays in the kitchen. On 8/30/22 at 8:23 AM, V1, Administrator, brought in a box of hair nets. V5, Dietary Aid, and V6, Cook, each put on a hairnet. On 8/30/22 at 8:28 AM, there was dust on the overhead light and pipe running above the toaster. On 8/30/22 at 8:29 AM, there was dust, dirt and reddish brown residue splattered behind the stovetop. On 8/30/22 at 8:30 AM in the standing refrigerator, there was a clear tub with a green lid labeled creamy chicken and noodles that was dated 8/12 with a use by date of 8/15. There was a clear tub with individual packages of ham, American cheese, and shredded cheddar cheese that had been opened and resealed, but were not dated. There…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-09-02 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, observation, and record review, the Facility failed to provide 80 square feet of floor space per resident in multiple resident bedrooms for 10 of 10 residents (R6, R7, R13, R19, R35, R37, R46, R47, R247, and R248) reviewed for floor space in the sample of 26. Findings include: The facility has six two bed resident rooms (107, 109, 110, 112, 115, and 117) that only provide 77.5 square feet per resident bed, as verified by historical measurement. These six rooms are certified for Medicare and Medicaid. R6, R7, R13, R19, R35, R37, R46, R47, R247, and R248 were reviewed for floor space and reside in the following resident rooms: 107, 109, 110, 112, and 115. All of these two bed rooms are on the 100 hallway and do not provide 80 square feet per resident bed. On 9/2/22 at 9:38 AM, V1, Administrator, stated, I am unaware of any room waivers, as are the Facility owners. No documentation was received from the Facility regarding waiver.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to maintain a clean and clutter-free environment for 3 of 4 residents (R6, R19, R47) reviewed for homelike environment in the sample of 26. Findings include: 1. On 8/30/22 at 10:28 AM, R6 was sitting in his room in front of his computer talking to his roommate, R19. R6 stated the bathrooms are always cluttered and dirty and the toilet seats are often dirty. R6's Face Sheet documents R6 was admitted to the facility on [DATE]. R6's Minimum Data Sheet (MDS) documents R6 is cognitively intact. 2. On 8/30/22 at 10:28 AM, R19 also complained that housekeeping does not do a good job of keeping the facility clean. He stated there was a smear of bowel movement on the bathroom floor for several days. R19's Face Sheet documents R19 was admitted to the facility on [DATE]. R19's MDS documents R19 is cognitively intact. 3. On 8/30/2022 at 9:00AM, R47's room was cluttered, the floor was not clean, and the walls were stained. The hallways outside the room…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-02 · 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, record review, and observation the facility failed to provide pressure ulcer treatments as ordered for one of five residents (R20) reviewed for pressure ulcers in the sample of 26. Findings Include: R20's Minimum Data Set (MDS) dated [DATE] documents R20 is severely cognitively impaired. R20's Physician Order Sheet (POS) dated 7/13/22 documents apply to Coccyx Dakin's solution (Sodium Hypochlorite) apply topically one time a day for wound care. Cleanse the wound with wound cleanser soak gauze in Dakin's and pack the wound leave for twenty minutes then remove packing. Then apply Silvadene, Gentamycin and Calcium Alginate cover with an abdominal bandage. R20's POS dated 8/31/22 documents cleanse coccyx with soap and water, NS (Normal Saline) or wound cleanser apply SSD (silver sulfadiazine) cream, cover with collagen powder and calcium alginate and dry dressing. Change daily and PRN (as needed for soilage or dislodgment). R20's August 2022 Treatment Administration Record (TAR) documents Dakin's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2023-10-24 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 80 square feet of floor space per resident bed for 10 of 53 residents (R6, R17, R18, R20, R27, R28, R30, R200, R201 and R202) reviewed for room size in the sample of 43. Findings include: On 10/17/2023 at 10:34 AM, V1, Administrator, stated there have been no changes to the historical measurements and accuracy of the facility's waivered resident room numbers and certifications. V1 stated there were 10 rooms on the 100 hall and all rooms were Medicare and Medicaid certified and provide 77.5 square feet per resident per bed. R6, R17, R18, R20, R27, R28, R30, R200, R201 and R202's room were measured on the 100 hallway and each room measured was less than 80 square feet per resident. Observations made throughout the survey from 10/17/2023 through 10/20/2023 demonstrate no concerns or complaints vocalized by residents in relation to waivered room size. On 10/18/2023 at 1:30 PM, during the group meeting no residents voiced any complaints or concerns regarding room size. The facility provided a list 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.

    Environmental 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

$73,886 in federal fines across 4 penalties. 1 Medicare payment denial on record.

  • $14,170 — penalty dated 2025-07-07
  • $30,602 — penalty dated 2024-04-26
  • $19,890 — penalty dated 2024-01-12
  • $9,224 — penalty dated 2023-10-24
  • Medicare payment denial — starting 2025-07-25 for 32 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.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$5.6M
Net patient revenuemost recent cost report
+10.1%
Operating marginrevenue minus expenses
$158K
Related-party expense3% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 9%Other / private 20%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $158K 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

$274per resident / day
operating cost
$8,325per month
≈ monthly operating cost
$305per 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 145785. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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