Oregon Living And Rehabilitation Center
811 South 10th Street, Oregon, IL 61061 · For profit - Limited Liability company · 104 certified beds · (815) 732-7994 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Apr 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (39) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 12.4% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.6% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.5% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.5% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.9% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.8% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 83.1% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 19.4% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.2% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 83.0% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 42.7% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 24.5% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.50 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.48 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
49.7% 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 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 36.7% 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 30 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 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.7%CMS range 38.0–62.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 6.2–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 36.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 33.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 91.7% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.3%CMS range 3.3–10.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 104 beds and averages 65.1 residents a day — about 63% occupied, or roughly 39 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 is at or above 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 3.08 hrs/resident/day on weekends vs 3.87 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.42 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
39 citations, most serious first. The 11 most serious are shown; the remaining 28 are one tap away and print in full.
- Actual harm · Gcited before2023-08-17 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure mechanically altered diets were the appropriate consistency. This failure resulted in R10 requiring emergency care after choking on pizza. This applies to 1of 19 (R10) residents reviewed for mechanically altered diets in the sample of 19. The findings include: The facility face sheet for R10 shows diagnosis to include chronic obstructive pulmonary disease, dysphagia and history of cerebral infarction. The facility assessment dated [DATE] shows R10 to be cognitively intact and requires limited assistance with eating. The Physician Order Sheet dated April 2023 shows R10 was ordered a mechanical soft texture diet. A nursing progress note dated 4/15/2023 shows R10 was feeding himself his dinner and was heard by staff to be coughing and spitting out mucous and pieces of pizza. The note goes on to show R10 was breathing but his airway sounded constricted, so the Heimlich maneuver was attempted with no success. 911 was called and R10 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow policy for obtaining vital signs for residents receiving skilled services for 3 of 3 residents (R1, R2, R3) reviewed for quality of care in the sample of 5.The findings include: 1. On 4/16/26 at 10:57 AM, V5 Licensed Practical Nurse said R1 was in the skilled care unit for therapy for a fractured sacrum. V5 said R1 was receiving oxygen via nasal canula. V5 said vitals including blood pressure, pulse, temperature, respirations, and oxygen saturations are taken on residents in the skilled unit daily and as needed. V5 said when a resident is on oxygen it is important to check oxygen saturations to make sure the resident is getting the right amount of oxygen and vitals help show if a resident is experiencing a change in condition.On 4/16/26 at 11:51 AM, V2 Director of Nursing said residents at the facility for skilled therapy have a full assessment and vitals taken every 24 hours and as needed. V2 said if the resident is on oxygen there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's pain was managed for 1 of 3 (R1) residents reviewed for pain in the sample of 5. The findings include: On 4/16/26 at 10:57 AM, V5 Licensed Practical Nurse (LPN) said R1 was in the skilled unit at the facility for therapy for a fractured sacrum. V5 said R1 was in a lot of pain and anxiety. V5 said R1 had hydrocodone-acetaminophen prescribed for pain.On 4/16/26 at 9:20 AM, V8 Complainant (R1's sister in law) said the facility was not meeting R1's needs by not controlling R1's pain.R1's Hospital Discharge Instructions dated 3/23/26 shows R1 was admitted to the hospital with acute hypoxic respiratory failure and a pelvic fracture after a fall on driveway. Orthopedics recommended a non-operative plan for now, as R1 is a high risk for surgery due to fragile respiratory status. Medication list: Hydrocodone-acetaminophen 10-325 mg tablet by mouth every 4 hours as needed for moderate pain.R1's Progress Note by V9 Medical doctor, dated 3/26/26…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-04-02 · tag F0755 — failed to provide safe pharmacy services — widespreadProvide 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
The facility failed to ensure accurate reconciliation and disposition of controlled substances. The facility also failed to have adequate policies for the reconciliation and disposition of controlled substances. These failures resulted in the facility being unable to account for a resident's controlled substances. This failure has the potential to affect all residents residing in the facility. The findings include:The facility provided census for 4/2/26 showed 65 residents resided at the facility. The facility's North Unit Controlled Substance Accountability Record Card-Sheet Count (commonly referred to as a card count sheet, CCS. The CCS is a count/record of the controlled substance cards, not the individual tablets. The facility also counted the controlled substance count sheets as well as the medication cards.) The facility was unable to produce the CCS for the North unit for the time period between the morning of 2/18/26 and the evening of 2/20/26. The following entries in the facility's CCS sheets were identified: 1.) 11/12/25 at 6:00 PM showed 1 controlled substance count…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-02 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent the diversion of a resident's controlled substance. This applies to 1 of 3 residents (R1) reviewed for misappropriation in the sample of 3. The findings include:R1's admission Record (Face Sheet) showed R1 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia, anxiety, and depression. R1's 2/26/26 Quarterly Minimum Data Set (MDS) showed she was unable to respond to questions such as her ethnicity and race, and she was unable to complete the Brief Interview for Mental Status test. R1's MDS showed she had short and long-term memory problems. The MDS showed she had not received as needed pain medication in the previous 5 days and she had no signs or symptoms of pain in the previous 5 days. R1's February 2026 Medication Administration Record (MAR) showed, Screen for pain every shift (three times a day). The entire month of February showed staff documented 0 for this pain assessment on a scale of 0 to 10. R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to report an allegation of misappropriation of resident property to the State Agency as well as local law enforcement. This applies to 1 of 3 residents (R1) reviewed for misappropriation in the sample of 3. The findings include:The facility's Investigation Report for 3/4/26 showed, On March 4, 2026, this writer (V1 Administrator) was informed of a potential misappropriation of a resident's narcotic medication. The concern was raised following the identification of a discrepancy in narcotic count records . A potential discrepancy (gap) was identified between narcotic counts and documented administration. A prn (As Needed) medication was delivered in months prior but no sheet or card could be located.It was determined that the discrepancy could have resulted from documentation errors, specifically: 1) Failure to sign out PRN narcotic medications at the time of administration. 2) Incomplete or missing entries on narcotic log sheets. 3) Improper paper handling.The investigation concluded that the initial concern of narcotic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-22 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement interventions to prevent a confused resident (R1) from wandering into another resident's (R2) room. This failure resulted in both residents being found in bed together and R2 was inappropriately exposed. This failure affected one (R1) of three residents reviewed for quality of care in the sample of 3.The findings include:1. Review of facility's final incident report reads in part: on 01/16/2026, staff entered a resident room and observed a fully dressed female resident lying in bed with a male resident. The male resident was unclothed. The male resident's hands were observed resting on the bed, and the female resident's hands were positioned at her sides. No movement or sexual activity was observed at the time of discovery. Both residents appeared calm and exhibited no signs of distress. Staff immediately separated the residents.A post-incident body assessment of the female resident revealed clothing intact with incontinence brief in place.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-25 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a dermatologist referral was sent when residents were experiencing skin rashes as ordered by the physician for six of ten residents (R1, R7, R8, R9, R10) reviewed for quality of care in the sample of ten. The findings include: 1. R1's admission Record shows he was admitted to the facility on [DATE]. R1's Order Summary Report shows an order for a dermatologist referral due to ongoing rash not improving with treatment. This order was entered on October 30, 2025. The facility's List of Rash Data dated 2025 shows R1 acquired a rash to his torso starting on October 11, 2025. On November 25, 2025, at 10:08 AM, R1 said that he has a rash on both of his arms and other places on his body. R1 said he gets cream applied, but it makes the itching worse. R1 said the facility does not know where the rash came from. 2. R7's admission Record shows he was admitted to the facility on [DATE]. R7's Order Summary Report shows an order for a dermatologist referral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-13 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure 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 that food was prepared appropriately to meet the needs of a resident with chewing difficulties for 1 of 3 residents (R1) reviewed for therapeutic diets in the sample size of 3. This failure resulted in R1 receiving diced ham instead of ground ham as recommended for a mechanical soft diet per facility's dietary spreadsheet recommendations and led to R1 having a choking episode.The findings include:R1's face sheet documented last admission date of 03/27/2025 with a past medical history not limited to vascular parkinsonism, dementia, anxiety, depression, dysphagia, and cognitive communication deficit.Review of R1's electronic medical records showed a speech therapy order dated 06/09/2025 for swallowing therapy related to treatment of swallowing dysfunction and treatment of oral function for feeding.R1's therapy/nursing communication form dated 07/01/2025 documented to continue with mechanical soft diet consistency .Review of nutritional care form dated 09/11/2025 completed by V9 (Registered Dietician)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the resident refrigerator was kept at a temperature at or below 41 degrees Fahrenheit. This applies to all residents in the building.The findings include:The facility's resident roster provided to surveyors on 9/9/25 showed 70 residents residing in the building.On 9/10/25 at 12:54PM, the resident food and drink refrigerator temperature was 44 degrees Fahrenheit. The refrigerator had many items of food and drink located in it.The facility's log for the resident food and drink refrigerator for September 2025 showed temperatures ranging from 44-48 degrees Fahrenheit from 9/1/25-9/10/25.On 9/10/25 at 1:07PM, V2 (Director of Nursing) stated, I believe night shift nurse's check the refrigerator temperature for the resident refrigerator. It should be below 42 degrees. If it's not, then they should adjust the dial in there and recheck it. V2 then obtained the form located on the front of the refrigerator and noted there are no directions for nurses to know what the acceptable temperature is or what actions to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 hot liquids were served at a safe temperature for all residents residing in the facility, failed to ensure a resident was transferred with a gait belt for 1 resident (R41). The findings include:1) The facility's roster provided to surveyors on 9/9/25 showed 70 residents residing in the building.On 9/9/25 at 12:20PM, V3 (Dietary Manager) showed surveyor the facility coffee and hot water machine. V3 stated, The machine is set to 205 degrees Fahrenheit. That is set by the company that services it.On 9/9/25 at 12:26PM, R34,R45,R54, and R61 all had hot coffee served to them. All residents stated the coffee was too hot to drink and it needed to cool awhile before drinking it. The coffee was observed to be steaming in all 4 resident's mugs.On 9/10/2025 at 7:58AM, V3 obtained the temperatures of the hot coffee and hot water that was poured into the carafes and being taken out to the dining area. The hot coffee temperature was 173 degrees…
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.
Show the remaining 28 citations
- Potential for harm · Ecited before2025-09-11 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent cross contamination during incontinence care, thoroughly clean a glucometer and blood pressure wrist cuff after use, and ensure hand hygiene was completed during medication administration for 4 of 4 residents (R73, R1, R60, & R10) reviewed for infection control in the sample of 36.The findings include: 1. On 9/9/2025 at 10:5l AM, V12 Certified Nursing Assistant (CNA) answered R73's call light and stated she needed to get items to change the resident due to being incontinent of urine and stool. At 10:58 AM, V12 CNA, V15 CNA, and V14 CNA came into R73's room to provide care; they all applied gloves. V12 held up a blanket and sheet in front of the resident's groin while V14 provided care. R73 was incontinent of urine and stool. V14 washed R73's groin and penis folding over washcloth as she did it. V14 rinsed and dried R73's groin and penis. R73 stated he needed to use the urinal. V14 did not change her gloves after providing care or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to report an allegation of misappropriation of resident property to the local health department and failed to report two allegations of misappropriation of resident property to the local authorities. This applies to 2 of 3 residents (R54 and R61) in the sample of 36. The findings include:1. R61's admission Record (Face Sheet) showed an admission date of 4/7/25.R61's misappropriation investigation, dated 8/27/25, showed Administrator (V1) was notified by [V7] Sister in law of [R61] that [R61] has had some money missing. [V7] stated that she gave [R61] 180 dollars in 20.00 bills on Saturday afternoon (8/23/25). This writer spoke to [R61] who stated that she received the money on Saturday afternoon and placed it in her purse that she keeps around her neck at all times and only removes it when she is sleeping. On Monday afternoon [R61] checked her purse and saw the money in her purse. On Tuesday afternoon it was gone. This writer searched for the resident's room and purse with resident present. This writer reviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
The facility failed to ensure hospice interventions were implemented as ordered for 1 of 1 resident (R6) reviewed for hospice in the sample of 36. The findings include:On 9/9/25 at 9:48 AM, R6 was laying on her left side in bed asleep. R6 had an air mattress in place that was not turned on. The setting on the sir mattress was set at 6. V12 Certified Nursing Assistant (CNA) was in the hall and was asked to check R6's air mattress. V12 confirmed the air mattress was not on and stated it should be turned on. V12 stated she did not know what the setting on the air mattress should be and would check with the nurse. On 9/9/25 at 10:34 AM, V10 Licensed Practical Nurse (LPN) stated R6 had the air mattress because hospice recommended it. V10 stated R6 had the air mattress due to her weight; she is small and bony. V10 stated the air mattress is to prevent pressure injury. On 9/9/25 at 10:36 AM, V13 LPN stated she flipped the switch on the air mattress and the green light came on. V13 confirmed the air mattress works; however, it had not been turned on. The Physician Orders for R6 dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete weekly wound assessments for a resident (R5), failed to identify a new pressure ulcer for a resident (R5), failed to develop a pressure ulcer care plan for a resident (R39). These failures apply to 2 of 4 residents reviewed for pressure ulcers in the sample of 36.The findings include:1) R5's electronic face sheet printed on 9/11/25 showed R5 has diagnoses including but not limited to vascular parkinsonism, dementia without behaviors, anxiety disorder, depression, mood disorder, and anemia. R5's facility assessment dated [DATE] showed R5 has mild cognitive impairment and has one stage 2 pressure ulcer. R5's care plan dated 6/13/25 showed, (R5) has pressure ulcers/skin breakdown related to advanced age resulting in natural thinning and fragility of skin, impaired cognition, unspecified dementia, impaired perfusion to the tissues, chronic kidney disease, need for assistance from staff with ADLs (Activities of Daily Living), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain accurate weights for a resident, failed to implement dietician recommendations for a resident. These failures apply to 1 of 1 residents (R44) reviewed for nutrition in the sample of 36.The findings include:R44's electronic face sheet printed on 9/11/25 showed R44 has diagnoses including but not limited to cerebral infarction, peripheral vascular disease, flaccid hemiplegia, and absence of left leg above knee. R44's facility assessment dated [DATE] showed R44 has no cognitive impairment. R44's care plan dated 7/10/25 showed, (R44) is at risk for nutritional problems .RD (Registered Dietician) to evaluate and make diet changes recommendations as needed. On 9/9/25 at 3:13PM, R44 stated he thinks he has had some weight loss but isn't sure how much. R44 stated he gets weighed on a monthly basis. R44's weight log showed, 6/19/25 149.1lbs, 6/22/25 172.3lbs (23.2lb weight gain within 3 days), 7/7/25 150.8lbs (21.5lb weight loss within 15 days). No…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-05 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a cognitively impaired resident was treated with dignity and respect by not preventing a staff member from communicating to the resident (R1) in an inappropriate and unprofessional manner while providing personal care services. This failure affected 1 of 4 (R1) residents reviewed for dignity in a sample size of 4. Findings include: R1's medical record indicated that resident last admitted to the facility on [DATE] with a past medical history not limited to: hypertension, dementia, anxiety, and urinary tract infection. R1's Minimum Data Set (MDS) Section C for cognitive patterns dated 02/19/2025 documented that R1's cognition is severely impaired. Review of facility's final incident report with incident date of 02/26/2025 at 1300 (1:00 PM) revealed that a comment was overheard outside the beauty salon. It was reported that the beautician [V3] stated to a resident, you b*h about a lot. Beautician was removed and investigation initiated.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-26 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's peripheral intravenous access site was flushed for 1 of 1 residents (R1) reviewed for intravenous catheters in the sample of 5. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include hypertension, systemic sclerosis, chronic heart failure, hepatic failure, atrial fibrillation, and reduced mobility. R1's February 2025 eMAR (electronic Medication Administration Record) showed an order for Sodium Chloride Solution 0.9%, use 10 ml intravenously every 8 hours for flush from 2/1/25 through 2/10/25. This eMAR shows R1's IV flush was not completed on the overnight shift on 2/2/25, 2/3/25, 2/6/25, and 2/7/25. R1's eMAR notes showed these were not completed due to not having an RN (Registered Nurse) available to administer them when they were scheduled. On 2/26/25 at 10:08 AM, V5 LPN (Licensed Practical Nurse) said R1 was on an intravenous push antibiotic that the facility's RN's were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide a homelike environment for 4 of 4 residents (R1, R2, R6, R7) reviewed for residents rights in the sample of 8. The findings include: R1's face sheet showed she was admitted to the facility 9/14/22 with diagnoses to include acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebrovascular disease, Type 2 diabetes, hypertension, hyperlipidemia, bipolar disorder, and anxiety disorder. R1's facility assessment dated [DATE] showed she has no cognitive impairment. R2's face sheet showed he was admitted to the facility 12/9/22 with diagnoses to include atherosclerotic heart disease, Type 2 diabetes, acute cystitis without hematuria, hyperlipidemia, mood disorder, anxiety disorder, and depression. R2's facility assessment dated [DATE] showed he has no cognitive impairment. R6's face sheet showed he was admitted to the facility 9/1/16 with diagnoses to include epilepsy, abnormalities of gait and mobility, major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure dishes were submerged in the sanitizing sink for at least 60 seconds and failed to ensure sanitized dishes were handled with clean hands. This has the potential to effect all 66 residents residing in the facility. The findings include: The CMS 671 dated 7/29/24 shows that there are 66 residents residing in the facility. Facility provided Diet Type Report dated 7/30/24 shows that there are no residents that receive a tube feeding and all residents receive food and drinks from the dietary department. 1. On 7/29/24 at 9:27 AM, V12 (Dietary Manager) used a chemical sanitizer test strip on a coffee mug after a cycle through the dish machine and the test strip showed there was no sanitizer being run through the machine. At 9:31 AM, V12 tried a second attempt and the test strip still showed there was no sanitizer being run through the machine. V12 then went to get maintenance to fix the dish machine. If the dish machine cannot be fixed, V12 said that staff will use the three-compartment sink to wash and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-31 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure opened, multi-dose vials/bottles of medication, including insulin pens and eye drops, were labeled with expiration dates for 5 of 5 residents (R15, R23, R41, R59, R14) reviewed for medication storage in the sample of 17. The finding include: R15's July 2024 Order Summary Report showed a physician order for R15 to receive 40 units of Glargine insulin, SQ (subcutaneously), twice a day. R23's July 2024 Order Summary Report showed a physician order for R23 to receive 14 units of Fiasp insulin, SQ, three times a day, before meals. R41's July 2024 Order Summary Report showed physician orders for R41 to receive 100 units of Tresiba insulin, SQ, at bedtime, and 6 units of Lispro insulin, SQ, before meals and at bedtime. R59's July 2024 Order Summary Report showed a physician order for R59 to receive 55 units of Lantus insulin, SQ, twice a day. R14's July 2024 Order Summary Report showed a physician order for R14 to receive one drop of Latanoprost eye drops, to both eyes, once a day at bedtime. On 7/29/24 at 9:50…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-31 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure residents receiving a pureed diet received a full four ounce (oz) scoop of pureed hamburger. This applies to 4 of 4 residents (R26, R24, R8, R55) reviewed for pureed diets in the sample of 17. The findings include: Facility Diet Type Report shows R26, R24, R8, and R55 receive pureed diets. Facility provided list of residents that use a three-compartment plate shows R26, R24, R8, and R55 receive their pureed meals in a three-compartment plate. On 7/29/24 at 11:59 PM, pureed bread, mashed potatoes, pureed green beans, and pureed hamburger were at the service line for pureed residents. The mashed potatoes, pureed green beans, and pureed hamburgers all had a 4 oz scoop. The pureed bread had a 1 oz scoop. All scoops were the correct sizes. On 7/29/24 between 12:00 PM and 12:45 PM, V15 (Cook) served and plated lunch for the facility. The portion sizes for residents receiving pureed foods in three-compartment plates appeared small. V15 would place the pureed bread and pureed hamburger in one compartment, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-31 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to implement and follow Enhanced Barrier Precautions (EBP) for 4 of 17 residents (R51, R10, R13, R14) reviewed for infection control in the sample of 17. The findings include: 1. R51's current care plan showed R51 required Enhanced Barrier Precautions related to his urinary catheter. On 7/29/24 at 12:03 PM, this surveyor knocked on R51's door and entered his room. No signage, identifying R51 was on EBP, was noted on or around R51's door. No cart containing PPE (personal protective equipment) was noted by the doorway to R51's room. Upon entrance to the room, R51 was seated in a recliner as V7 (Certified Nursing Assistant/CNA) stood next to R51, holding onto R51's urinary catheter. V7 wore a mask and gloves but had no protective gown on. Once V7 repositioned himself in the recliner, V7 (CNA) left the room to obtain supplies to provide cares to R51 as he was incontinent of a large amount of mushy stool. At 12:07 PM, V7 (CNA) returned to R51's room and began providing incontinence care to R51. V7 wore a mask and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 professional standards were met by nursing during medication administration. This failure applies to 1 of 3 residents (R23) observed in the medication pass. The findings include: R23's July 2024 Medication Administration Record (MAR) showed medication orders for R23 as the following: a) Depakote 250 mg (milligrams) Delayed Release, give 250 mg by mouth, two times a day at 8 AM and 8 PM, for depression. b) Lantus insulin 100 unit/ml (milliliter), inject 35 units subcutaneously (SQ), two times a day at 8 AM and 8 PM, for Type 2 Diabetes Mellitus. c) Fiasp insulin, 100 unit/ml, inject 14 units SQ, before meals at 7:30 AM, 11:30 AM, 5:30 PM, for Type 2 Diabetes Mellitus. The MAR showed a second order for R23 to also receive Fiasp insulin, SQ, per sliding scale based on R23's glucose level (if glucose is 100-150, give 2 units; 151-200, give 4 units, 201-250, give 6 units; 251-300, give 8 units), before meals and at bedtime, at 7:30 AM, 11:30 AM, 5:30 PM, 8 PM. d) Norco 5/325 mg, give one tablet, three times 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.
- Potential for harm · Dcited before2024-07-31 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with dysphagia was assessed by speech therapy after a choking episode and failed to ensure residents were transferred in a safe manner. These failures apply to 3 of 17 residents (R10, R51, R40) reviewed for safety and supervision in the sample of 17. The findings include: 1. R10's admission Record dated 7/29/24 shows R10's diagnoses include, but are not limited to, Parkinsonism, tracheostomy status, gastro-esophageal reflux disease, dysphagia, seizures, and traumatic brain injury. R10's Minimum Data Set, dated [DATE] under the heading Swallowing Disorder, shows R10 has coughing or choking during meals or when swallowing medications. R10's Progress notes dated 3/13/24 at 6:33 PM show R10 was coughing with food in her mouth and three nurses attempted to assist R10 to clear her airway. R10 was getting air through her stoma (tracheostomy) and was finally able to clear her airway. R10 had abnormal lung sounds and was sent to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to maintain a resident's urinary catheter tubing and urinary drainage bag below the level of a resident's bladder to prevent infection for 1 of 4 residents (R51) reviewed for urinary catheter care in the sample of 17. The findings include: R51's current care plan showed R51 had a urinary catheter in place due to his diagnoses of urinary incontinence and neuromuscular dysfunction of his bladder. The care plan showed, Position catheter bag and tubing below the level of the bladder . On 7/29/24 at 12:03 PM, R51 was seated in a recliner in his room with V7 (Certified Nursing Assistant/CNA) standing next to R51. V7 held R51's urinary catheter bag at her waist (at the level of R51's head) as R51 attempted to reposition himself in the recliner. An obvious backflow of urine was noted in the catheter tubing, towards R51. On 7/30/24 at 11:57 AM, V2 (Director of Nursing) stated a resident's urinary catheter bag and tubing is to be kept below the level of the resident's bladder so there is no backflow of urine which could…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were monitored during medication administration for 2 of 17 residents (R53, R19) reviewed for medication administration in the sample of 17. The findings include: On 7/29/24 at 9:58 AM, R53 was lying in bed in her room. An orange pill was sitting on R53's bedside table in a medicine cup. R53 said the nurse brought her medications, but she doesn't want to take that pill today and she needs to throw it away. R53's admission Record dated 7/29/24 shows R53 was admitted to the facility on [DATE] with a principle admitting diagnosis of dementia. On 7/29/24 at 10:05 AM, R19 was sitting in a chair next to his bed. A pill was in a medicine cup on his bed. R19 said the pill is for the pain in his feet. R19 said the nurse brings his medication in when he is still sleeping and leaves it. R19 said his pain starts in the afternoon, so he will keep it and take it later. R19 said he gets the medication (which he said is Gabapentin) three…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to respond to the pharmacist's notification that a resident's PRN (as needed) anti-anxiety medication order had no end date. This failure applies to 1 of 5 residents (R6) reviewed for psychotropic medications in the sample of 17. The findings include: R6's Order Summary Report showed a new physician order, dated 4/5/24, for R6 to receive Lorazepam (anti-anxiety medication) 0.5 mg (milligrams), every 4 hours as needed (PRN) for anxiety. The report showed no stop date for the medication. R6's Pharmacy Consultant Medication Regimen Review assessments dated 4/25/24, 5/16/24, and 6/21/24 each showed V17 Consulting Pharmacist repeatedly requested a stop date for R6's PRN Lorazepam order dated 4/5/24. R6's Note to Attending Physician/Prescriber form dated 6/23/24 showed, 3rd request Resident has a PRN psychotropic order, Ativan (Lorazepam) 0.5 mg q4 hours PRN, but does not have criteria in place for use beyond 14 days. The form showed R6's physician renewed the Lorazepam order due to R6's agitation and psychosis. On 7/31/23 at 9:12…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure as needed (PRN) anti-psychotic medications had a stop date of fourteen days. This applies to 2 of 5 residents (R56, R6) reviewed for unnecessary medications in the sample of 17. The findings include: 1. R56's Order Summary Report dated 7/30/24 shows lorazepam oral concentrate 2 MG/ML (milligrams per milliliter), give 0.25 mL (milliliters) by mouth every 2 hours as needed for agitation related to unspecified psychosis not due to a substance or known physiological condition. R56's order for lorazepam has a start date of 12/29/23 and does not have a stop date. 2. R6's Order Summary Report showed a new physician order, dated 4/5/24, for R6 to receive Lorazepam (anti-anxiety medication) 0.5 mg (milligrams), every 4 hours as needed (PRN) for anxiety. The report showed no stop date for the medication. R6's Pharmacy Consultant Medication Regimen Review assessments dated 4/25/24, 5/16/24, and 6/21/24 each showed V17 (Consulting Pharmacist) repeatedly requested a stop date for R6's PRN Lorazepam order dated 4/5/24. R6's Note…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to administer medications on time and as ordered. There were 28 medication administration opportunities with 5 errors resulting in a 17.86% error rate. This failure applies to 1 of 3 residents (R23) observed in the medication pass. The findings include: R23's July 2024 Medication Administration Record (MAR) showed medication orders for R23 as the following: a) Depakote 250 mg (milligrams) Delayed Release, give 250 mg by mouth, two times a day at 8 AM and 8 PM, for depression. b) Lantus insulin 100 unit/ml (milliliter), inject 35 units subcutaneously (SQ), two times a day at 8 AM and 8 PM, for Type 2 Diabetes Mellitus. c) Fiasp insulin, 100 unit/ml, inject 14 units SQ, before meals at 7:30 AM, 11:30 AM, 5:30 PM, for Type 2 Diabetes Mellitus. The MAR showed a second order for R23 to also receive Fiasp insulin, SQ, per sliding scale based on R23's glucose level (if glucose is 100-150, give 2 units; 151-200, give 4 units, 201-250, give 6 units; 251-300, give 8 units), before meals and at bedtime, at 7:30 AM, 11:30 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure residents' medications were administered as prescribed to avoid significant medication errors for 2 of 17 residents (R23, R25) reviewed for medication administration errors in the sample of 17. The findings include: 1. R23's July 2024 Medication Administration Record (MAR) showed medication orders for R23 as the following: a) Depakote 250 mg (milligrams) Delayed Release, give 250 mg by mouth, two times a day at 8 AM and 8 PM, for depression. b) Lantus insulin 100 unit/ml (milliliter), inject 35 units subcutaneously (SQ), two times a day at 8 AM and 8 PM, for Type 2 Diabetes Mellitus. c) Fiasp insulin, 100 unit/ml, inject 14 units SQ, before meals at 7:30 AM, 11:30 AM, 5:30 PM, for Type 2 Diabetes Mellitus. The MAR showed a second order for R23 to also receive Fiasp insulin, SQ, per sliding scale based on R23's glucose level (if glucose is 100-150, give 2 units; 151-200, give 4 units, 201-250, give 6 units; 251-300, give 8 units), before meals and at bedtime, at 7:30 AM, 11:30 AM, 5:30 PM, 8 PM. d) Norco…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to supervise a resident with dementia in a manner to prevent choking on a non-food item for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 4. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia without behavioral disturbance, vascular dementia, severe, with other behavioral disturbance, falls, age-related osteoporosis, mood disorder, anxiety disorder, and insomnia. R1's facility assessment dated [DATE] showed she has severe cognitive impairment, exhibits frequent wandering behaviors, and requires supervision with ambulation. R1's care plan initiated 5/9/24 showed, [R1] has impaired cognition due to diagnoses dementia and will place non-food items in her mouth and attempt to swallow Staff will monitor resident during mealtimes. When [R1] leaves the table, staff will redirect [R1] to the table or monitor her in the common area . R1's care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-17 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure there was a Registered Nurse (RN) working 8 hours a day, 7 days a week. This affects all the residents residing in the facility. The findings include: The facility's CMS 672 Form dated 8/15/23 showed there were 65 residents residing at the facility. The facility's working schedules for 8/1/20 - 8/20/23 showed there was not an RN working at least 8 hours on the weekend of 8/12/23 and 8/13/23. (V2 (DON - Director of Nursing) was handwritten in on the schedule.) On 8/17/23 at 9:36 AM, V2 (DON) said the facility had an average census of 60-65 residents. V2 said she had not been providing direct resident care, except a 4 hour shift at the end of July. V2 said she was not aware that the DON did not count towards the facility's requirement to have a RN at least 8 hours a day, 7 days a week. V2 said the facility does not have many RNs. The surveyor reviewed the schedule with V2. V2 agreed she was the only RN scheduled on 8/12 and 8/13/23. The facility's Facility Assessment Tool (reviewed 4/27/23) showed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-08-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the dishwasher sanitization levels were maintained. This affects all the residents residing in the facility. The findings include: The facility's CMS 672 Form dated 8/15/23 showed there were 65 residents residing in the facility. On 8/15/23 at 9:17 AM, V8 (Dietary Aide) was standing at the handwashing station, in the dish room. V8 said she was finishing the breakfast dishes. The surveyor asked if the dishwasher could be tested. V3 (Dietary Manager) walked into the dish room, obtained the chlorine test strips, and waited for the appropriate dish cycle. After the water was released from the dishwasher, V3 dipped the test strip in a small run off area, in the front of the machine. The test strip went from white to a light gray color. V3 stated, Hmmm, that's strange, and obtained another test strip. V3 dipped the test strip in the same water runoff and the result was still light grey. The key on the chlorine test strips showed, Grey = 10PPM; Light Purple = 50; Dark Purple = 100; and Black = 200. V3 stated,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-17 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure pureed food was made in a way to conserve flavor and nutritive value for 10 residents (R1, R2, R9, R10, R19, R20, R25, R36, R47, R58) on pureed diets. The findings include: The facility's Diet Type Report showed there were 10 residents on pureed diets (R1, R2, R9, R10, R19, R20, R25, R36, R47, R58). On 8/15/23 at 10:57 AM, V6 (Cook) said she was ready to begin the pureed process. V6 had a small, square pan full of peas on the stove. The surveyor asked V6 if the peas were measured. V6 replied, I don't have to measure them. I just know that I need to fill that container to make enough for the 10 pureed diets that I have. V6 did not use a recipe to prepare the pureed food. V6 dumped the entire pan of peas into the blender and turned it on. V6 walked over to the sink with a small stainless steel pitcher and filled it with water. V6 stated, I like to use REALLY hot water to make my pureed food. V6 poured some of the water to the blender, then added more. V6 did not measure the amount of water she was adding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have preventive measures in place or follow the wound care physician orders for a resident with a stage II pressure ulcer for 1 or 1 residents (R23) reviewed for pressure ulcers in the sample of 19. The findings include: On 8/16/23 at 11:10 AM, V4 (Wound Care Nurse) and V18 LPN (Licensed Practical Nurse) were at R23's bedside to change her pressure ulcer dressing to her left sacral area. V4 turned R23 onto her left side and assisted her to stay in that position. V18 pulled R23's pants and incontinence briefs down and removed a dressing to R23's left coccyx that was bunched up/rolled into itself on one side. The area under the dressing was a slit type wound with redness around the open area. V4 wound nurse stated the area was reddened. V18 changed the dressing. V4 laid R23 onto her back in bed and did not offload the pressure ulcer. R23 did not have an air mattress in place to her bed. V4 stated R23 sits at activities. V4 stated the 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.
- Potential for harm · Dcited before2023-08-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents were safely positioned in their wheelchairs for 2 of 6 residents (R59 and R19) reviewed for safety and supervision in the sample of 19. The findings include: 1. On 8/15/23 at 10:24 AM, R59 was sitting in a high backed wheelchair without footrests in activity area. R59 had grip socks on both of his feet. V16 CNA (Certified Nursing Assistant) pulled R59's wheelchair back from the table in the activity area and starts to push his wheelchair forward to the bathroom. R59 had his right leg crossed over his left leg and his left foot was dragging across the floor as she pushed his wheelchair. V16 stopped halfway to the bathroom and asked R59 if his feet were off of the floor; they weren't. V16 didn't wait for a reply and continued to push R59 to the bathroom in his wheelchair with the bottom of his foot dragging across the floor. The Face Sheet dated 8/16/23 for R59 showed medical diagnoses including dementia, benign prostatic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 oxygen equipment was stored in a manner to prevent cross contamination, failed to document the rate of oxygen administration, and failed to document the rationale and assessment for a resident receiving oxygen for 1 of 1 resident (R5) reviewed for oxygen administration in the sample of 19. The findings include: R5's face sheet shows an [AGE] year-old female with diagnosis of congestive heart failure, hypertension, cardiomegaly, and Type 2 diabetes. On 08/15/23 at 09:04 AM, R5 was in her room in bed. There was an oxygen concentrator (not in use) next to her bed. The oxygen tubing was uncovered and laying over the side of the machine towards the wall. R5 said she had pneumonia about 6 weeks ago and used the oxygen for several days. On 08/17/23 at 09:39 AM V13, Care Plan Nurse said she did not see an oxygen care plan for R5. The purpose of a care plan is to make sure resident's care needs are identified and individual goals,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-17 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to prevent cross contamination of resident contact surfaces by not removing gloves and washing hands after providing incontinence care and before touching anything else in the resident's room for 1 of 3 residents (R45) reviewed for infection control in the sample of 19. The findings include: On 8/15/23 at 9:27 AM, V16 CNA (Certified Nursing Assistant) and V17 CNA were at R45's bedside to provide perineal care. V16 and V17 had gloves on. V16 went to sink to get wet washcloths and sat them on a towel on R45's bed. V17 pulled down right side of R45's pants, turned the resident on her left side and unfastened the incontinence brief. V16 and V17 turned R45 onto her right side, pulled her pants down and removed her incontinence brief. They placed R45 on her back and then finished removing her pants. V16 took wet washcloths and cleaned the left side of R45's groin, folded the washcloth then wiped R45's vaginal area. V16 folded the washcloth and washed the right side of R45's groin. V16 disposed of the washcloth in a bag…
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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HERMAN, MOSHE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 09/01/2011 |
| MILSTEIN, ARI | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 09/01/2011 |
| MILSTEIN, STUART | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 09/01/2011 |
| MINKOVE, ELANA | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 7% | since 09/01/2011 |
| BETTNER, FELISHA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2025 |
| ENGLEHART, ERIK | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/28/2026 |
| PAYTON, DANA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/15/2018 |
| MOMENTUM HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2011 |
CMS files one row per role, so the 15 rows in the source record cover these 8 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.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $650K paid to related parties — landlords or management companies under common ownership — equal to about 10% 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145476. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.