Allure Of Pinecrest

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.

59.1% 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 70 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.0% 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 36 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 0.17 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 125 beds and averages 92.8 residents a day — about 74% occupied, or roughly 32 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.22 hrs/resident/day on weekends vs 3.65 on weekdays — 12% thinner on weekends. RN hours go from 0.55 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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.

38 citations, most serious first. The 18 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Jcited before2024-05-13 · 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 assess and monitor a resident that experienced a change in condition and failed to implement interventions as ordered by the physician resulting in the death of one of 18 residents (R93) reviewed for quality of care in the sample of 18. The Immediate Jeopardy began on April 27, 2024 at 11:00 AM when V9 CNA (Certified Nursing Assistant) reported a change in condition to V10 LPN (Licensed Practical Nurse) and V10 instructed V9 to wait until R93's lunch tray arrives. V1 Administrator was notified of the Immediate Jeopardy on May 9, 2024 at 11:08 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on May 10, 2024 at 10:00 AM, but non compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the inservice training. The findings include: R93's admission Record shows he was admitted to the facility on [DATE] with diagnoses including mild intellectual…

  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 · G2026-04-13 · tag F0659 — isolated
  Provide care by qualified persons according to each resident's written plan of care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide documentation showing staff was qualified to replace a gastrostomy tube (g-tube) per standards of practice for 1 of 4 residents (R1) reviewed for staff qualifications in the sample of 4. This failure resulted in R1's g-tube migrating into the small intestines leading to complications requiring hospitalization.Findings Include: On 4/13/26 at 12:10 PM, V1 (Administrator) said she did not know if V2 had any certification or training on changing a urinary catheter g-tube and to ask V2 directly. On 4/13/26 at 12:16 PM, V2 (Director of Nursing/DON) said she was not sure what prompted R1's urinary catheter g-tube to be changed, the nurse approached her and said the family wanted her to change it. V2 said it was a routine procedure, a standing order, and she didn't speak with V10 (R1's Physician). V2 said she replaced R1's 16 French with a 20 French urinary catheter because R1's stoma had stretched and the 20 French and the feeding would go in easier.…

  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
• Actual harm · Gcited before2026-04-13 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to monitor a urinary catheter gastrostomy tube (g-tube) placement, failed to have policies in place for the care of a urinary catheter g-tube, and failed to have polices in place for replacing a urinary catheter g-tube for 1 of 2 residents (R1) reviewed for gastrostomy tubes in the sample of 4. This failure resulted in R1's being hospitalized due to her gastrostomy tube advancing into her small intestine causing a partial small bowel obstruction and pancreatitis.Findings Include: On 4/9/26 at 10:09 AM, V13 (R1's son) said after R1's g-tube was replaced, the tube was leaking. The only part of the tube sticking out of R1 was the nipple on the end. V9 and V2 were at the bedside looking at R1's g-tube. V2 asked him if he did this, which he told her no. Shortly after R1 was sent to the emergency room. V13 said R1 was exhibiting pain and the tube feeding was leaking all over. On 4/9/26 at 12:22 PM, R1 was sitting in a wheelchair at the nurses'…

  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 before2024-09-23 · 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 obtain the necessary weights on residents (R1, R5) with diagnosis of congestive heart failure (CHF). The facility failed to obtain and complete the necessary lab work on resident (R1) with diagnoses of CHF and chronic kidney disease. These failures contributed to R1 being re-hospitalized with diagnoses of fluid overload and an exacerbation of CHF. These failures apply to 2 of 5 residents (R1, R5) reviewed for necessary care and services in the sample of 5. The findings include: 1. R1's hospital discharge instructions dated 12/20/23 showed R1 was hospitalized , from 12/10/23-12/20/23, due to bacterial endocarditis (infection around the heart) and respiratory failure. The discharge instructions also showed R1 had diagnoses of congestive heart failure (CHF) and chronic kidney disease. The instructions showed R1 was discharged to the facility on [DATE], for skilled therapy and rehab services, with an order for, Labs: CBC (complete blood count), Creatinine…

  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 · G2024-05-13 · 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 nutritional supplements as ordered for one of three residents (R64) reviewed for weight loss in the sample of 18. This failure contributed to R64 experiencing a 11.41% weight loss in the last six months. The findings include: R64's Order Summary Report dated May 7, 2024, shows she was admitted to the facility on [DATE], with diagnoses including wandering, generalized anxiety disorder, history of falling, depression, alzheimer's disease, dementia, need for assistance with personal care, and difficulty walking. R64 has pudding with lunch ordered on December 15, 2023, and health shake three times per day ordered on October 3, 2023. R64's meal ticket shows for R64 should have received a mighty vanilla shake and a pudding cup at lunchtime. On May 7, 2024, at 12:10 PM, R64 was sitting at the lunch table for her lunch meal. R64 had a general diet food tray in front of her and was eating small bites of food with her fingers. There was a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-09 · 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 resident's safety while using a mechanical stand lift machine for 1 of 3 residents (R1) reviewed for safety in the sample of 6. This failure resulted in R1 having a decline in the ability to raise her left arm, and R1's Physician diagnosing R1 with a complete rotator cuff tear. The findings include: R1's admission Record, printed by the facility on 11/8/23, showed she had diagnoses including enterocolitis due to clostridium difficile (C-diff), generalized osteoarthritis, hypertension, a history of falling, iron deficiency anemia, atrial fibrillation, chronic kidney disease, seizures, unsteadiness on feet, lack of coordination, and weakness. R1's care plan, with a revision date of 11/8/23, showed R1 requires sit to stand by staff to transfer. R1's alteration in skin integrity care plan, with a revision on 11/1/23, showed R1 received a skin tear measuring 0.5 cm (centimeters) x 0.3 cm. Skin is very fragile. Cleansed and dry…

  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 before2023-08-03 · 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 ensure a resident (R12) with a change of condition was assessed and monitored after exhibiting an altered mental status. This failure resulted in R12 being admitted to the hospital with, hypoglycemia and sepsis related to a UTI (urinary tract infection). The facility also failed to ensure a resident received x-ray services without any delay for R57 following a fall. This failure resulted in R57 waiting 18 hours for an x-ray, and the x-ray showed a fractured hip requiring surgical intervention. This applies to 2 of 2 residents (R12, R57) reviewed for quality of care in the sample of 18. The findings include: 1. R12's admission record documents her admission date to be 5/12/23 with a most recent hospitalization of 7/15/23 to 7/24/23. The diagnoses list includes morbid obesity, need for assistance with personal care, and protein-calorie malnutrition. A diagnosis of hypoglycemia (low blood sugar) was added 7/24/23. The 7/13/23 office clinic notes for V15 FNP (Family Nurse Practitioner) documents R12 has had a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-08-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify a pressure injury before becoming a Stage 2 or greater and failed to provide initial wound assessments for 2 of 4 residents (R14, R5) reviewed for pressure injuries in the sample of 18. This failure resulted in R14 developing two Stage 2 and one Stage 3 pressure injuries. The findings include: 1. On 8/1/23 (between breakfast and lunch), R14 was in his room in his wheelchair. At 12:22 PM, R14 was self-propelling in his wheelchair after leaving the dining room. On 8-/1-8/3/23, this surveyor had no observations of R14 in any other position than up in his chair. On 08/01/23 at 1:10 PM, V2 Director of Nursing (DON) said the facility could not provide a list of residents with wounds (pressure or non-pressure). V2 said the facility did not have a wound nurse and nobody did wound tracking at this time. It fell through the cracks during COVID and was to be a focus this August. V2 was unable to provide the date R14's wounds were first noted…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-01 · 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 document resident assessments for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3.The findings include:R1s face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to dementia, transient cerebral ischemic attack, atrial fibrillation, presence of cardiac pacemaker, and hypertension.R1s nursing progress notes for [DATE] document at 9:23 AM, resident observed during medication administration to have difficulty swallowing a pill and began exhibiting signs of choking. The Heimlich maneuver was performed, abdominal thrust, CPR (cardiopulmonary resuscitation) was initiated, and she was sent to the emergency room. The record did not indicate R1s return, her assessment upon return including vital signs or any new orders from the emergency department.On [DATE] at 12:47 PM, V3 Licensed Practical Nurse LPN said I want to say I was still her nurse when she came back and definitely…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-13 · 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

  Based on observation, interview, and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4.Findings Include:On 4/9/26 at 12:14 PM, V3 (Certified Nursing Assistant/CNA) said R1 is alert to self only and is dependent on staff for all care. V3 said R1 is nonverbal and cries out often. V3 said R1 is incontinent of bowel and bladder. On 4/9/26 at 12:22 PM, R1 was sitting in a wheelchair in the nurses' station. R1 was alert and looking around the room but did not respond when spoken to.On 4/9/26 at 2:16 PM, V6 (CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. V6 said V7 spoke out loud, this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked. V6 said later in the shift, V7 told her she did not know V13 was in the room. V6 said told V7 that is why you watch what you say.…

  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 before2026-04-13 · 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

  Based on interview and record review the facility failed to report an allegation of abuse to the state agency for 1 of 4 residents (R1) reviewed for abuse in the sample of 4.Findings Include:On 4/9/26 at 2:16 PM, V6 (Certified Nursing Assistant/CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. V6 said V7 spoke out loud, this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked. V6 said V7 was inappropriate and said things that she wouldn't say to her own child. V6 said she talked to someone about it that day but was not sure who. V6 said it is not appropriate to talk to residents that way. On 4/9/26 at 2:52 PM, V1 (Administrator) said V8 reported to her that V7 was inappropriate and used curse words when providing care for R1. V1 said she went and talked to V13, who told her V7 was inappropriate and asked her to educate the nurses. V1 said since V13 didn't…

  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 · D2026-04-13 · 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

  Based on interview and record review the facility failed to ensure an allegation of verbal abuse was investigated for 1 of 4 residents (R1) reviewed for abuse in the sample of 4.Findings Include: On 4/9/26 at 2:16 PM, V6 (Certified Nursing Assistant/CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. V6 said V7 spoke out loud, this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked. V6 said V7 was inappropriate and said things that she wouldn't say to her own child. V6 said she talked to someone about it that day but could not recall whom. V6 said it is not appropriate to talk to residents that way. On 4/9/26 at 2:52 PM, V1 (Administrator) said V8 reported to her that V7 was inappropriate and used curse words when providing care for R1. V1 said she went and talked to V13, who told her V7 was inappropriate and asked her to educate the nurses. V1 said since…

  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 before2026-04-07 · 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 observation, interview, and record review the facility failed to ensure assessed elopement interventions were in place for 3 of 3 sampled residents (R1, R2, R3) at risk for elopement and failed to ensure the elopement alert system was implemented at exit doors in resident areas. These failures resulted in R1 exiting through a resident wing door on 3/26/26 at 5:35 AM and found by staff at 5:38 AM walking outside in the dark approximately 50 feet down the facility's sidewalk with a slope to the right side, without a walker, and without wearing her elopement alert bracelet or temperature appropriate clothing.Findings include:1. On 4/1/26 at 9:00 AM, the facility's wing 3 had an exit door at the end of the hall. This exit door had a banner with a stop sign across the door, attached to each side of the door frame. This surveyor opened the door, and an alarm was heard overhead wing 3 door open. There was a sidewalk beyond the door that went straight out approximately 20 feet and then turned sharply left…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-12 · 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 prevent a cognitively impaired resident from leaving the facility unsupervised for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.The findings include:On 3/12/26 at 11:50 AM, R1 was in her room with V14 (Licensed Practical Nurse-LPN). R1 was heard screaming. V14 was attempting to help R1 zip her coat. R1 was adamant about wearing her coat, even though she was inside the building. V14 was attempting to get R1 to lay in bed for some rest. R1 was resistive and back up wandering out into the hall. V14 said she was assigned to provide one on one supervision for R1 today. R1 continued to ambulate throughout the unit and was very difficult to redirect. R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include vascular dementia with other behavioral disturbance, hypertension, insomnia, and disorders of muscle. R1's facility assessment dated [DATE] showed R1 has severe cognitive…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-10 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 interview and record review the facility failed to ensure a resident's medical record contained documentation of a change of condition for 1 of 3 residents reviewed for medical record accuracy in the sample of 4.The Findings include:R3's face sheet documents she was admitted to the facility on [DATE] with multiple diagnoses including gastrostomy status, and cognitive communication deficit. R3's 1/9/26 care plan documents she requires a tube feeding related to dysphagia (difficulty swallowing).The 2/1/26 emergency department documents R3 arrived at 5:36 AM with a chief complaint of a pulled out feeding tube. The notes show a temporary tube was placed with an outpatient procedure to be scheduled to replace the percutaneous endoscopic gastrostomy (PEG).R3s facility record was reviewed and had no details relating to an incident of R3s PEG tube being dislodged or coming out. The notes do not show she left the facility. On 2/10/26 at 12:06 PM, V5 certified nursing assistant said during her rounds last week,…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-13 · 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 the wound care provider of a resident's critical lab value prior to wound care. This applies to 1 of 3 residents (R1) reviewed for notification in the sample of 5. The findings include:R1's admission Record (Face Sheet) showed an admission date of 8/12/25 with diagnoses to include but not limited to stage four pressure ulcer to the left heel, atrial fibrillation (rapid/irregular heartbeat), and left hip fracture. R1's Face Sheet showed she was discharged from the facility on 11/6/25. R1's October 2025 electronic medication administration record (eMAR) showed an order for 3 milligrams of Warfarin (anticoagulant) to be given at bedtime. The eMAR showed the order was started on 9/23/25; it was not given on 10/8/25 then the order was discontinued on 10/9/25. R1's Lab Result Report from 10/8/25 collected at 6:32 AM and reported at 5:26 PM showed her International Normalized Ratio (INR, a lab result used to measure a person's ability to clot and is used to determine therapeutic dosages of anticoagulants like Warfarin.…

  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 before2025-08-07 · 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 ensure the safety and supervision was maintained for 2 of 3 residents (R1, R2) reviewed for elopement in the sample of 3. The findings include:On 8/6/2025 R1 was observed in the activity room, sitting in a recliner. R1 looked at surveyor and smiled when surveyor waved at him. R1 was observed at 3:46 PM in the dining room in another activity. R1 was sitting at a table with other residents and their family. R1 was smiling while sitting at the table. R2 was observed on 8/6/2025 sleeping while sitting up, on a couch on the 300 wing. R2 was observed on 8/7/2025 during the lunch meal eating. V2 (unit coordinator/social services) was sitting next to R2 encouraging intakes. R2 was observed being assisted with walking to his room and being provided personal cares. R2 was resistive to care at first, but staff were able to convince R2 to allow them to assist him. On 8/6/2025 at 3:07 PM, V3 (Licensed Practical Nurse-LPN) said she was not working when the incidents…

  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 · E2025-04-30 · tag F0805 — failed to prepare food in a form residents can eat — pattern
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  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 pureed pork was pureed to a pudding-like consistency. This applies to 4 of 4 residents (R390, R60, R339, R1) reviewed for pureed diets in the sample of 19. The findings include: Facility provided list of residents on a pureed diet shows R390, R60, R339, and R1 receive pureed diets. On 4/28/25 at 10:04 AM, V13 (Cook) started the puree process for the pureed pork. V13 measured out and weighed enough pork for four servings of pureed pork. V13 placed the pork into a blender pitcher with broth and started to puree the pork. At 10:09 AM, V13 stopped the blender and tested the consistency. V13 said it wasn't quite ready at that time and that the pork tends to be a little stringy and more difficult to puree. At 10:10 AM, V13 stopped the blender, tested it a second time and said it was much better. V13 placed the pureed pork into a food service pan and into the oven. On 4/28/25 at 10:11 AM, the first finished batch of pureed pork appeared to be lumpy as V13 scooped it into the food service pan. On 4/28/25 at…

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

  Nutrition and Dietary 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

$188,633 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $66,330 — penalty dated 2026-03-04
• $30,030 — penalty dated 2024-09-16
• $72,149 — penalty dated 2024-05-13
• $20,124 — penalty dated 2023-11-09
• Medicare payment denial — starting 2026-04-02 for 68 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 ALLURE HEALTHCARE SERVICES — 15 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 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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 $678K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in IL