Metropolis Rehab & Hcc

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

51.6% 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 172 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 47.0% 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 83 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 101 beds and averages 63.7 residents a day — about 63% occupied, or roughly 37 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.483 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.95 hrs/resident/day on weekends vs 3.70 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.72 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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

58 citations, most serious first. The 26 most serious are shown; the remaining 32 are one tap away and print in full.

• Immediate jeopardy · J2026-04-03 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to notify a medical provider of elevated blood glucose levels for 1 (R4) of 3 residents reviewed for glucose monitoring. This failure resulted in R4 having blood glucose levels greater that 600 putting R4 at risk to develop Diabetic Ketoacidosis (DKA) which could result in coma and possible death.The Immediate Jeopardy began on 3/2/26 at approximately 8:00 AM when R4's blood glucose reading was not obtained and sliding scale insulin was not administered per Physician orders. V1 (Administrator), V11 (Assistant Director of Nursing/ ADON), V2 (Director of Nursing/ DON), V12 (Licensed Practical Nurse/ LPN/ Wound Nurse), V22 (Regional Clinical Director), and V23 (Regional Director of Operations) were notified of the Immediate Jeopardy on 3/20/26 at 9:06 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/19/26, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-26 · 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

  Based on observation, interview, and record review the facility failed to prevent, identify, and treat Moisture Associated Skin Damage (MASD) and failed to follow physician orders for lab testing after a change in condition for 2 (R1 and R2) of 3 residents reviewed for change in condition in a sample of 7. This failure resulted in R2 developing wounds that caused pain due to MASD.Findings include:1. R2's admission Record documented an admission date of 7/19/17 with diagnoses including multiple sclerosis, abnormalities of gait and mobility, and abnormal posture.R2's 4/7/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section GG documented R2 was dependent for toileting hygiene and section H documented R2 was always incontinent of bowel and bladder.R2's Care Plan documented a revised 5/24/23 focus area of (R2) has potential/ actual impairment to skin integrity r/t MS (related to multiple sclerosis), decreased mobility with a 5/24/23 intervention of Monitor pressure areas for changes in color,…

  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 plan of correction
• Actual harm · Gcited before2026-05-26 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide prescribed pain medication to 1 (R5) of 3 residents reviewed for medication administration in a sample of 7. This failure resulted in R5 experiencing lower back pain that radiated down her legs causing increased pain and insomnia. Findings include:R5's admission Record documented an admission date of 12/30/25 with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side, hypertensive urgency, hyperosmolality and hypernatremia, personal history of transient ischemic attack and cerebral infarction without residual deficit, type 2 diabetes mellitus, unspecified viral hepatitis C without hepatic coma, borderline personality disorder, mild persistent asthma, unsteadiness on feet, muscle weakness, hypokalemia, essential hypertension, hypoxemia, and weakness. R5's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R5…

  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 plan of correction
• Actual harm · Gcited before2026-05-26 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to administer an antianxiety medication for 1 (R4) of 3 residents reviewed for medication administration in a sample of 7. This failure resulted in R4 developing withdrawal symptoms including insomnia, sweating, and shaking.Findings include:R4's admission Record documented an original admission date of 11/8/23 with diagnoses including early onset cerebral ataxia, anxiety disorder, and depression. R4's 4/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R4 was cognitively intact.R4's Care Plan Report documented a revised 1/7/26 focus area of R4 has anxiety and currently takes anxiety medications with a 2/12/24 intervention of administer medication as ordered and monitor/ document for side effects and effectiveness.R4's Order Summary Report documented a 3/30/26 order for Ativan 0.5 mg 1 tablet every morning and at bedtime for anxiety.On 5/21/26 at 1:32 PM, R4 said a couple weeks ago the facility ran out of her Ativan and did not tell R4. R4 said she had…

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

  Pharmacy Service Deficiencies · Deficient, Provider has plan of correction
• Actual harm · Gcited before2026-04-03 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure residents are free from significant medication errors for 5 (R4, R5, R9, R12, and R11) of 8 residents reviewed for medication administration in a sample of 14. This failure resulted in R9 experiencing a lack of sleep and feeling exhausted throughout the day.Findings include:1. R9's admission Record documented an admission date of 1/26/20 with diagnoses including: insomnia, adult failure to thrive, and type 2 diabetes mellitus with diabetic polyneuropathy.R9's 1/14/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R9 was cognitively intact.R9's Care Plan report documented a revised 8/20/24 focus area documenting in part . (R9) has diabetes mellitus (R9) is non-compliant with her diet. with 5/31/22 intervention documenting in part . Diabetes medication as ordered by doctor. Monitor/ document for side effects and effectiveness. and a revised 12/12/25 focus area documenting in part . disturbed sleep pattern, insomnia. with a 12/12/25 intervention…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-11-17 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat residents with dignity and respect related to timely response to requests for assistance, valuing residents' private space, and refraining from practices that have the potential to feel demeaning or intimidating for 6 (R4, R8, R9, R10, R33 and R37) of 6 residents reviewed for resident rights in the sample of 46. This failure resulted in R8 experiencing feeling vulnerable, belittled, and intimidated and would cause a reasonable person to feel frustration and humiliation when R4 was put to bed without the opportunity to toilet and subsequently was incontinent. Findings Include: 1. R8's admission Record documented an admission date of 05/20/25 and included diagnoses of encounter for other orthopedic aftercare, muscle weakness, type 2 diabetes mellitus, sleep apnea, occlusion and stenosis or unspecified cerebral artery, seizures, diverticulitis of intestine, radiculopathy, and dizziness and giddiness. R8's MDS dated [DATE] documents a BIMS score 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-11-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were free from staff abuse for 2 of 3 residents (R6 and R19) reviewed for abuse in the sample of 46. This failure resulted in R19 being spat in the face by a staff member which would cause a reasonable person to experience feelings of humiliation, anger and fear and resulted in staff verbally abusing R6 causing R6 to be visibility upset and fearful.Findings Include:1. The facility Final Reportable for R19 dated 10/02/25 documents under Complete Description of Occurrence: Initial Report: Initial: Abuse Coordinator was notified on 10/2/2025 at around 10:30pm about an alleged incident that took place between a staff member and resident, (R19). Staff were immediately suspended. Police, Family Representative and Physician were notified. Immediate investigation was initiated. Final: A thorough investigation was conducted between October 2, 2025, and October 8, 2025. Interview Statements: Resident, (R19) was unable to state what…

  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 before2025-11-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure physician orders were accurate and implemented for recommended changes in treatment after a hospitalization and a fall, and failed to assess and treat lymphedema/wounds per physicians orders for 3 of 3 residents (R6, R7, R20) reviewed for quality of care/treatment in a sample of 46. This failure resulted in R6 struggling to breathe, causing anxiety, sleep disturbance, and significant discomfort due to recommended medications changes not being administered/implemented to treat newly diagnosed congestive heart failure. This failure also resulted in R7's developing redness, increased swelling, tenderness, and altered mental status and R7's subsequent hospitalization with a diagnosis of cellulitis and septic shock.Findings include:1. R6's admission Record documented an admission date of 02/06/25 and included diagnoses of acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease (COPD) with acute exacerbation,…

  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 before2025-11-17 · 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 the prescribed diets, nutritional supplements and the appropriate portion sizes according to the approved menus for 7 of 7 residents (R2, R3, R13, R15, R18, R19 and R42) reviewed for weight loss in a sample of 46. This failure further contributes to continued harm to R3 and R18, who are currently considered severely thin and underweight. Findings include:1. R3's admission Record documents an admission date of 05/14/24 with diagnoses including: Alzheimer's disease with late onset, dementia, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, pleural effusion, abnormal posture, and body mass index 19.9 or less.R3's Minimum Data Set (MDS) dated [DATE] documents a dash for the question, should brief interview for mental status (BIMS) be conducted? and a dash for the BIMS summary score. R3's MDS section L documents none of the above were present with the boxes included B. no natural teeth or tooth…

  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 before2025-11-17 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide pain medications for pain management for 3 of 3 residents (R4, R5, and R31) reviewed for pain in the sample of 46. This failure resulted in R4 and R31 not having the medications available used to treat their pain resulting in uncontrolled pain. Findings Include:1. R4's admission Record with a print date of 10/01/25 documents R4 was admitted to the facility on [DATE] with diagnoses that includes polyneuropathy.R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03, indicating R4 has a severe cognitive deficit.R4's current Care Plan documents a Focus area of (R4) has pain. Date Initiated: 01/22/2025. This Focus area includes the intervention of, Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Date Initiated 01/22/2025.R4's Order Summary…

  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 before2025-11-17 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 1. ensure medications were available to be administered as ordered, 2. ensure medications were administered timely, and 3. ensure medications were stored in a secure area for 6 of 6 residents (R4, R5, R19, R31, R35, and R45) reviewed for pharmacy services in the sample of 46. This failure resulted in R4 and R31 not receiving their pain medication and R4 and R31 crying with uncontrolled pain.Findings Include:1(a). R4's admission Record with a print date of 10/01/25 documents R4 was admitted to the facility on [DATE] with diagnoses that includes polyneuropathy.R4's MDS (Minimum Data Set) dated 8/29/25 documents a BIMS (Brief Interview for Mental Status) score of 03, indicating R4 has a severe cognitive deficit.R4's current Care Plan documents a Focus area of (R4) has pain. Date Initiated: 01/22/2025. This Focus area includes the intervention of, Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms,…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-05 · 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 A. Based on observation, interview and record review the facility failed to provide assistance in a manner to prevent falls for 2 (R5 and R10) of 6 residents reviewed for falls in a sample of 16. This failure resulted in R10 sustaining a large intracranial hematoma, left eyebrow laceration and a left periorbital hematoma and R5 sustaining a skin tear to right shin and right shoulder along with a forehead laceration requiring 4 sutures. Findings include: 1. R10's admission Record documents an admission date of 12/02/2019 with diagnoses including: acute cystitis without hematuria, unspecified Escherichia coli as the cause of diseases classified elsewhere, encephalopathy, hemiplegia affecting left non-dominant side, history of transient ischemic attack and cerebral infarction without residual deficits, osteoarthritis right shoulder, cerebral infarction, other abnormalities of gait and mobility, other lack of coordination, blepharoconjunctivitis of the left eye, third nerve palsy of left eye, history of covid-19,…

  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 · G2024-05-10 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide peritoneal dialysis treatments for 1 of 2 residents (R1) reviewed for dialysis in a sample of 7. This failure resulted in R1 presenting with a change in condition of confusion and being admitted to the hospital with lethargy and receivng hemodialysis during R1's hospital stay. Findings include: R1's admission Record documents R1's initial admission date to the facility as 03/25/24. The same document lists diagnoses for R1 including but not limited to: End Stage Renal Disease, Dependence on Renal Dialysis, Syncope and Collapse, Muscle Weakness (Generalized), Other Lack of Coordination, and Type 2 Diabetes Mellitus Without Complications. R1's current care plan, with an initiation and revision date of 4/16/24, documents a need of hemodialysis related to renal failure. There was no documentation of the need for peritoneal dialysis prior to this date upon request. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, a Brief Interview for…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to safely transport a resident in a wheelchair to prevent an accident for 1 of 3 residents (R1) reviewed for accidents in the sample of 6. This failure resulted in R1 receiving an 8 cm (centimeter) laceration over his right eye requiring 10 staples. The findings include: R1's face sheet documents R1 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, Parkinson's Disease with dyskinesia, with fluctuations, and repeated falls. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 01, indicating that R1 has severe cognitive impairment. Section GG, Functional Abilities and Goals, of the same MDS documents that R1 uses a wheelchair as a mobility device, R1 requires partial/moderate assistance (helper does less than half the effort) with sit to stand, walking 10 feet, and walking 50 feet with two turns. The same section…

  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 before2023-10-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's wheelchair had foot rests in place when transporting a resident outside of the facility for 1 (R1) of 7 residents reviewed for accidents. This failure resulted in R1's foot dropping and pulling back under the wheelchair resulting in a closed fracture of distal end of the right tibia. This past non-compliance occurred between 10/12/23 and 10/18/23. The findings include: R1's admission record documents an admission date to the facility of 4/13/18 with diagnoses including bipolar disorder, sepsis, unspecified organism, orthostatic hypotension, unspecified osteoarthritis, unspecified site. Additional diagnoses include displaced spiral fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing dated 10/12/23. R1's MDS (Minimum Data Set) section C, dated 10/12/23, note that R1 has a BIMS (Brief Interview of Mental Status) of 12 indicating R1 has moderate cognitive impairment. The same MDS section GG…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2023-05-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure ulcers were assessed, treated, and interventions were implemented timely for 1 of 3 (R66) residents reviewed for pressure ulcers in the sample of 36. This failure resulted in R66 developing a Stage 3 Pressure Ulcer to R66's coccyx which was up to 1 week old before it was assessed and treated. Findings Include: R66's facility admission Record with a print date of 5/24/23 documents R66 was admitted to the facility on [DATE] with diagnoses of fracture of femur, cirrhosis of liver, fracture of ribs, neurocognitive disorder, diabetes, and fracture of vertebra. R66's MDS (Minimum Data Set) dated 4/23/23 documents a BIMS (Brief Interview for Mental Status) score of 02, which indicates R66 has a severe cognitive deficit. This same MDS documents R66 is dependent on staff for bed mobility and toilet use and requires extensive assistance with transfers. This same MDS documents under Section M, R66 is at risk for developing pressure…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-05-26 · tag F0809 — failed to serve meals on a reasonable schedule — widespread
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  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 meals were served at the scheduled times posted. This failure has the potential to affect all 62 residents residing in the facility. Findings include: R2's admission documented an admission date of 7/19/17. R2's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R5's admission Record documented an admission date of 12/30/25. R5's MDS assessment dated [DATE] documented a BIMS score of 15, indicating R5 was cognitively intact. R7's admission Record documented an admission date of 11/25/25. R7's MDS assessment dated [DATE] documented a BIMS score of 14, indicating R7 was cognitively intact. On 5/20/26 at 2:47 PM, R5 and R7 stated they always eat in their room and the meals are always delivered late. R7 said breakfast was usually on time but the noontime and evening meals are sometimes 30 minutes to an hour and a half late. On 5/21/26 at 1:47…

  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 plan of correction
• Potential for harm · Dcited before2026-05-26 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure timely acquisition of medication refills for 2 (R4 and R5) of 3 residents reviewed for medications in a sample of 7.Findings include:1. R4's admission Record documented an original admission date of 11/8/23 with diagnoses including early onset cerebral ataxia, anxiety disorder, and depression. R4's 4/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating R4 was cognitively intact.R4's Care Plan Report documented a revised 1/7/26 focus area of R4 has anxiety and currently takes anxiety medications with a 2/12/24 intervention of administer medication as ordered and monitor/ document for side effects and effectiveness. R4's Order Summary Report documented a 3/30/26 order for Ativan 0.5 mg 1 tablet every morning and at bedtime for anxiety.On 5/21/26 at 1:32 PM, R4 said a couple weeks ago the facility ran out of her Ativan and did not tell R4. R4 said she had experienced withdrawal…

  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 plan of correction
• Potential for harm · Fcited before2026-04-30 · 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 maintain effective sanitizer levels to sanitize food contact surfaces and failed to maintain kitchen equipment in a safe and sanitary condition. This failure has the potential to affect all 64 residents residing in the facility.Findings include:On 4/29/26 at 9:53 AM during a walk-through of the kitchen, the garbage disposal had chunks of food and clotted milk floating in it with a large amount of water running into the floor from around the seals of the garbage disposal under the sink. Water was pooling in the floor and running into the floor drain. A strong odor of rotting food was noted around the garbage disposal. The sprayer above the garbage disposal had hard water buildup in the center of the nozzle causing water to spray outwards onto the wall, floor, and surrounding area. The pipes to the ice machine in the kitchen beside the walk in cooler was leaking water down the wall and pooling in the floor. The Heating, Ventilation, and Air Conditioning (HVAC) unit in the kitchen had a large amount of brownish…

  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 before2026-04-03 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to provide enough staff to perform Activities of Daily Living (ADL) care for dependent residents for 2 (R9 and R14) of 3 residents reviewed for ADL care in a sample of 14. This failure has the potential to affect all 13 residents residing on the 100 hall.Findings include:1. R9's 1/14/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R9 was cognitively intact.R9's Care Plan Report documented a revised 6/8/22 focus area documenting in part .(R9) has an ADL self care performance deficit activity intolerance, hemiplegia. with a revised 6/1/22 intervention documenting in part . bathing: this resident requires 1 staff participation with bathing. and a revised 2/27/24 intervention documenting in part . Transfer: the resident requires 2 staff participation with transfers.On 3/17/26 at 10:59 AM, V19 (Certified Nursing Assistant/ CNA) said she had worked the hall R9 resided by herself within the week prior to this interview. V19 said if a staff member is working 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-04-03 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to administer medications within the ordered times and had a medication error rate of 96.8% medication error rate for 4 (R5, R11, R12, and R13) of 8 residents reviewed for medication administration.Findings include:On 3/13/26 at 10:51 AM, V4 (Registered Nurse/ RN) said she was still passing the 8:00 AM medications. V4 said she never had her medications administered on time. V4 said there was no limit on how many residents a nurse could have and it was not realistic to get all the medications passed.1. R11's admission Record documented an admission date of 3/4/22 with diagnoses including major depressive disorder, schizophrenia, and epilepsy.On 3/13/26 at 11:21 AM, V4 was observed administering R11's lamotrigine 25 mg 1 tablet, levetiracetam 500 mg/ 5ml 5ml oral liquid, risperidone 0.25 mg 1 tablet, sennosides- docusate 8.6 - 50 mg 1 tablet, and topiramate 25 mg 1 tablet.R11's March 2026 Medication Administration Record documented the following medication orders with the start date proceeding: 2/11/26 lamotrigine…

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

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

  Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL) care for dependent residents for 1 (R9) of 3 residents reviewed for ADL care for dependent residents in a sample of 14.Findings include:R9's admission Record documented an admission date of 1/26/20 with diagnoses including: insomnia, adult failure to thrive, and type 2 diabetes mellitus with diabetic polyneuropathy.R9's 1/14/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R9 was cognitively intact.R9's Care Plan Report documented a revised 6/8/22 focus area documenting in part .(R9) has an ADL self care performance deficit activity intolerance, hemiplegia. with a revised 6/1/22 intervention documenting in part . bathing: ther resident requires 1 staff participation with bathing. and a revised 2/27/24 intervention documenting in part . Transfer: the resident requires 2 staff participation with transfers.On 3/17/26 at 11:29 AM, V19 (Certified Nursing Assistant/ CNA) said resident shower sheets are prefilled out with…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-03 · 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

  Based on observation, interview, and record review the facility failed to follow accepted standards of practice in maintaining infection control while providing incontinence care to 1 (R5) of 3 residents reviewed for Activities of Daily Living (ADL) in a sample of 14.Findings include:R5's admission Record documented at admission date of 7/21/24 with diagnose including need for assistance with personal care, reduced mobility, and cognitive communication deficit.R5's 2/21/26 Minimum Data Set (MDS) section H documented R5 was always incontinent of bowel and bladder and section GG documented R5 required substatntial/ maximal assistance with toileting hygiene.On 3/20/26 at 3:48 PM, the surveyor entered R5's room and observed V11 (Assistant Director of Nursing) and V18 (Certified Nursing Assistant) to have R5's pants down around his knees with R5's incontinence brief wet with urine. Using her gloved hands, V18 took R5's pants off and threw them onto the floor. V11 and V18 removed R5's urine soiled incontinence brief and V18 threw it on the floor. V18 picked up a wet washcloth draped 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-03-05 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation, and record review the facility failed to provide enough staff to meet the needs of the residents timely. This failure has the potential to affect all 62 residents residing at the facility.Findings include:The facility Assignment location list dated 02/27/26 documents 62 residents residing at the facility.On 02/27/26 at 9:04 PM, R1 was sitting at the nurses' station in her wheeled recliner asleep with her head leaning against the wall.On 02/27/26 at 9:15 PM, V5 (Licensed Practical Nurse) was passing medications. V5 was the only staff member visualized on the 100 and 200 hall.On 02/27/26 at 9:15 PM, V5 stopped her medication pass and responded to a resident that was yelling out then went back to her med (medication) cart and attempted to start med pass again when another call light went off. V5 stopped med pass to attend to the call light again. After attending to that call light she started med pass again.On 02/27/26 at 9:17 PM another call light was activated, V5 finished giving the medication she was working on to a resident and went and checked 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-03-05 · tag F0807 — failed to offer suitable drinks — pattern
  Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
  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 drinks with meals for 4 (R1, R2, R3, and R4) of four residents reviewed for hydration in a sample of 8.Findings include:On 03/01/26 at 5:28 PM during the evening meal, R1 was seated in the dining room at a table with her food in front of her and did not have a drink in front of her.On 03/01/26 at 5:28 PM during the evening meal, R2 was seated in the dining room at a table with her food in front of her with approximately one third of her food eaten with no drink in front of her.On 03/01/26 at 5:28 PM during the evening meal, R3 was seated in the dining room at a table with her food in front of her with approximately one third of her food eaten with no drink in front of her.On 03/01/26 at 5:28 PM during the evening meal, R4 was seated in the dining room at a table with his food in front of him with approximately three quarters of his food eaten and no drink in front of him. On 03/01/26 at 5:44 PM R1, R2, R3, and R4 still did not have drinks in front of them and they still had food in front of them 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to update and implement interventions to care plans for one (R1) of three residents reviewed for care plans in a sample of 8.Findings include:R1's admission record documents an admission date of 05/14/24 with diagnoses including: Alzheimer's disease with late onset, dementia, chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, pleural effusion, abnormal posture, and body mass index 19.9 or less. R1's minimum data set (MDS) dated [DATE] documents R1 is severely impaired in making decisions regarding tasks of daily life.R1's care plan documents: R1 has impaired cognitive function/dementia or impaired thought processes Alzheimer's, Dementia. Date initiated 5/14/24. R1 has a behavior problem with agitation, she often rejects care and becomes physically/verbally aggressive with staff, physically and verbally aggressive during cares. Date initiated 5/21/24. Interventions listed of: behavior #2: agitation:…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$361,369 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $179,545 — penalty dated 2026-04-03
• $147,680 — penalty dated 2025-11-17
• $10,913 — penalty dated 2024-05-10
• $12,048 — penalty dated 2024-03-07
• $11,183 — penalty dated 2023-10-31
• Medicare payment denial — starting 2025-12-07 for 2 days

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

Part of a chain

This home belongs to TUTERA SENIOR LIVING & HEALTH CARE — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 22 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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

What families pay in IL