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Aliya Of Palos Park

12220 South Will Cook Road, Palos Park, IL 60464 · For profit - Corporation · 129 certified beds · (630) 257-2291 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited May 2024Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$327,435 in federal fines2 Medicare payment denials
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited May 2024
  • 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
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (48) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $327,435 in federal fines (most recent 2025-07-31)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
12430 S Post Rd · (708) 923-0969 · Call to confirm hours
Pharmacy
11981 W 143rd St · (708) 403-9221 · Call to confirm hours
Grocery
Meijer2.6 mi
14169 S Bell Rd · (708) 645-5800 · Call to confirm hours
Park
131st Street, Orland Park , 60467, United States · (800) 870-3666 · Typically dawn to dusk
Place of worship
12154 Will Cook Rd · (708) 361-1810

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 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 held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.7%13.4%15.4%better
Long-stay residents who lose too much weight3.7%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms93.1%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.5%3.1%3.3%typical
Long-stay residents whose ability to walk worsened7.1%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.0%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine87.4%91.8%95.3%typical
Long-stay residents with pressure ulcers2.8%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control29.4%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.5%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine63.7%63.1%79.4%worse
Short-stay residents rehospitalized after admission32.0%26.1%22.6%worse
Short-stay residents with an outpatient ER visit11.4%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.712.021.67typical
Long-stay outpatient ER visits per 1,000 resident days1.692.221.80typical

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.

51.5% 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 320 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.5%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
63.5%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 63.5% 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 145 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 0.33 therapist hours per resident per day in 2026Q1 — more than 55% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF51.5%CMS range 45.6–56.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.8–13.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge67.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.6%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.5–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.58
RN hours/ resident / day
0.91
LPN hours/ resident / day
1.81
Aide hours/ resident / day
3.29
Total nurse hours/ resident / day
0.54
RN hoursweekends
54.8%
Total nursing turnover
47.4%
RN turnover

How full it usually is: this home is certified for 129 beds and averages 122.5 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.18 hrs/resident/day on weekends vs 3.34 on weekdays — 5% thinner on weekends. RN hours go from 0.59 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%.

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

15
deficiencies at the latest standard inspection (2025-04-25)
7
at the previous standard inspection (2024-05-17)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

48 citations, most serious first. The 20 most serious are shown; the remaining 28 are one tap away and print in full.

  • Immediate jeopardy · J2024-01-30 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to ensure one resident's airway (R4) with a tracheostomy was free of obstruction by not removing the inner cannula during Cardiopulmonary Resuscitation (CPR) attempts. This affected one of three (R4) residents reviewed for emergency management. This failure resulted in R4 remaining in respiratory distress and the facility was unable to locate a spare trach tube to provide emergency oxygen during a Code Blue. R4 was transported to the local emergency room and pronounced deceased on the same day. The Immediate Jeopardy began on [DATE] when R4 developed respiratory distress and staff were unable to locate inner trach tube to provide oxygen and clear R4's airway. V7 (Administrator) was notified on [DATE] at 10:54 AM. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 1.18.24, but noncompliance remains at Level two because additional time is needed to evaluate the implementation and effectiveness of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-09-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide adequate supervision and implement effective care plan interventions for one resident (R2) who was reviewed for falls. This failure resulted in R2 experiencing a right hip fracture as a result of a fall.Findings include:R2 has multiple diagnoses including but not limited to the following: delirium, altered mental status, acute kidney failure, metabolic encephalopathy, dementia, insomnia, psychosis, cognitive communication deficit, difficulty walking, and lack of coordination.Fall Risk Evaluation dated 7/13/2025 shows R2 has a fall risk score of 22.0 indicating resident is at high risk for falls.It is to be noted that R2 was sent to the emergency room following a fall on 7/16/2025 and has not returned to the facility.Facility Reported Incident states in part but not limited to the following: On 7/16/2025 at approximately 6:28AM, V5 (Licensed Practical Nurse) was monitoring R2 in the dining area. R2 stood and attempted to walk, despite V5's attempt to redirect. R2 stumbled and fell to the floor, landing on her right…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-08-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their hospice policy and care plan for one (R2) out of three residents reviewed for mechanical lift for transfer from chair to bed. This failure resulted in R2 sustaining a laceration on her left leg that required R2 to be sent to the emergency room for suturing. The after-emergency room summary indicates that R2 was treated for laceration repair. The facility's final summary investigation indicates that R2 returned to the facility with 17 sutures. Findings include:On 8/19/2025 at 11:37 AM, V4(Hospice CNA) said that V4 was transferring R2 to the bed, and V4 bumped R2's leg on the bed. V4 said that was when V4 saw the blood and V4 ran to get the nurse. V4 said that V4 transferred the resident from the wheelchair to the bed by herself. V4 said that R1 is a mechanical lift transfer resident. V4 said that V4 just did not use the mechanical lift and that was a mistake on V4's part. On 8/20/2025 at 1:50 PM, V4 said that V4 has been working with R2 for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-07-31 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to conduct comprehensive assessment and implement wound care management for one (R1) of three residents reviewed for skin alteration. This deficiency resulted in R1's abrasion on the left great toe deteriorated to necrosis, gangrene, infection of left foot, and needs amputation. Findings include:R1 is an [AGE] year-old, male, admitted in the facility on 07/03/25 with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; Type 2 Diabetes Mellitus without Complications; Pain in Right Foot; Pain in Left Foot; and Multiple Subsegmental Thrombotic Pulmonary Emboli without Acute Cor Pulmonale. MDS (Minimum Data Set) dated 07/10/25 recorded R1's BIMS (Brief Interview for Mental Status) score is 0, which means severe cognitive impairment.R1's progress notes documented:07/03/25: received R1 in stable condition. The left great toe had a D/I (debridement and irrigation) done, has…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-04-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat elevated blood sugars that were above the resident's baseline before it got to a critical level and the facility failed to put in any interventions for a resident experiencing vomiting and diarrhea to prevent dehydration. This affected two of three (R81, R84) reviewed for nursing quality of care. This failure resulted in R84 being sent to the hospital with a blood sugar level of 521 mg/dL and was diagnosed with uncontrolled diabetes and R81 being sent to the hospital to be treated for severe dehydration after being diagnosed with norovirus. Findings Include: R81 is an [AGE] year old with the following diagnosis: chronic obstructive pulmonary disease, nontraumatic intracerebral hemorrhage, chronic kidney disease, congestive heart failure, and peripheral vascular disease. R81 was at the hospital from [DATE] through the evening of 4/23/25. A Nursing note dated 4/18/25 at 2PM documents the nurse was notified by staff that R81 appeared to be choking.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-07-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to implement effective fall intervention to prevent a resident from falling which resulted in resident walking by herself, falling, and sustaining a left hip fracture. This failure affected 1 resident (R2) of 3 residents reviewed for falls in a total sample of 15. Findings include: On 7-3-24 at 11:12 AM, V2 (Director of Nursing) said R2 is primarily Spanish speaking and R2 can make simple needs known. V2 said R2 has poor safety awareness due to dementia, impulsive behaviors, and gets up by herself without asking for assistance. V2 said R2 will become aggressive during redirection which could lead to falls. V2 said R2 has unsteady gait and requires 1-person assistance and assistive walking device. V2 said R2 is a fall risk. V2 said CNA cleaned, dressed, and brought R2 to common area. V2 said high fall risk residents were grouped in common area and supervised. V2 said CNA left the group to give ADL care. On 7-3-24 at 8:50 AM, V20 (Certified Nurse Aide) said R2 is alert and able to make her need known in simple terms since R2 is…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-05-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to supervise one resident while sitting in the dining room unattended who was identified as a high fall risk and has a diagnosis of Dementia, syncope, and a history of falls. This failure resulted in R401 having an unwitnessed fall from her wheelchair sustaining a left hip fracture. The facility also failed to utilize a leg rest during a transport for a wheelchair bound resident. This failure resulted in R61 having a fall from the wheelchair sustaining a right forehead hematoma. These failures affected two of three residents reviewed for falls in a total sample of 26. Findings Include: R401 was diagnosed with Dementia, Syncope and Collapse. Minimal data set Section GG (functional abilities and goals) dated 3/31/24 documents: R401 required partial/moderate assistance for sit to stand (the ability to come to a standing position from sitting in a chair. Helper lifts, holds or support trunk or limbs but provides less than half the effort). Comprehensive…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-05-17 · tag F0776 — isolated
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    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 have a system to track requests for diagnostics services to ensure timely x-ray services are provided to residents. This failure resulted in R5 being transported to the hospital after waiting over 30 hours for x-ray service and being diagnosed with multiple rib fractures for one of one reviewed for diagnostic services in a total sample of 26. Findings include: R5 was admitted to the facility on [DATE] with a diagnosis of syncope, unsteadiness on feet, orthostatic hypotension, restless leg syndrome, unspecified dementia and anxiety disorder. R5's Minimum Data Set, dated [DATE] documents brief interview for mental status is 12/15 which indicates cognitively intact. On 5/14/24 at 3:10 PM, R5 who was alert and oriented to self, place and time at time of interview said he was in his room, was putting on a jacket when he lost his balance and fell backwards hitting his left side on the heating/air conditioning wall unit and windowsill. The next day he 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-01-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow physician orders and implement wound care treatment for a resident with a noted stage 2 pressure sore. This affected one of three residents (R1) reviewed for pressure sores. This failure resulted in R1's wound worsening requiring debridement and progressing to a stage 3. Findings include: R1 face sheet shows R1 has diagnosis of weakness, diabetes mellitus. On 1/9/23 at 1:00pm V5 (director of nursing) presents document dated 9/6/23 denoting R1 skin color, texture, turgor normal. No rashes or lesions. On 1/9/23 at 11:13am V9 (wound care coordinator) said the nurse documented that R1 was admitted on [DATE] with a wound, V9 said when she assessed R1 on 9/11/23 R1 did not have any skin issue, R1 skin was intact. V9 said she can't explain the documentation of the nurse. V9 said on 9/16/23 the floor nurse informed her that R1 had skin issue on her tail bone. V9 said the floor nurse got an order for hydrocolloid. V9 said on 9/18/23 she…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-09-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to have an effective plan to monitor/supervise resident identified to be high risk for falls This affected one of three residents (R1) reviewed for falls and fall prevention. This failure resulted in R1 falling from bed and sustaining a non-displaced transverse fractures demonstrated on the right side at the C6 and C7 levels. Findings include: R1 has diagnosis including but not limited to Displaced Fracture of Seventh Cervical Vertebra, Difficulty in Walking, Fracture of Neck, Dysphagia, Cerebral Infarction, Hypertension, Dementia, and Depression. R1's cognitive assessment dated [DATE] indicates R1 is severely impaired. R1's bowel and bladder assessment dated [DATE] states R1 is always incontinent of urine. R1's functional status states she requires extensive assistance with bed mobility, dressing, and personal hygiene. R1 is total dependent on staff for toileting assistance. R1 was initially admitted to the facility on [DATE]. On 9/5/23 at 1:26PM V3,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to respect a resident's (R1) right by tampering with a camera in the resident's room. This failure affected one resident in a sample of 9. R1 is [AGE] years old with diagnosis not limited to: Metabolic Encephalopathy, Moderate Protein-Calorie Malnutrition, Acute Respiratory Failure With Hypoxia, Adult Failure To Thrive, Chronic Kidney Disease, Retention of Urine, Acute Cystitis Without Hematuria, Syncope and Collapse, Thoracic Aortic Aneurysm, Anemia, Obstructive And Reflux Uropathy, Constipation, Hypothyroidism, Dementia, Insomnia, Parkinson's Disease, Major Depressive Disorder. R1's 4/2/26 BIMS score is 00 (meaning the resident is not cognitively intact). R1's 11/10/25 care plan documents in part: R1's POA (Power of Attorney) prefers to have camera in her brother's room. On 5/8/26 at 12:38 pm R1 was observed. R1 was clean but was not able to be interviewed. On 5/8/26 at 2:00 pm V1 (Administrator) said regarding R1, she was informed on 4/17/26 that a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician orders pertaining to pressure ulcer prevention and failed to follow the facility's pressure ulcer policy. These failures affected one resident (R1) out of a sample of three residents reviewed for pressure ulcers. Findings include: R1's face sheet documents in part the following diagnoses: Metabolic encephalopathy, dysphagia, protein-calorie malnutrition, unspecified dementia, cognitive communication deficit, local infection of the skin, cellulitis of the right lower limb, Parkinson's disease, and major depressive disorder. R1's minimum data set (3/11/2026) documents in part a brief interview of mental status (BIMS) summary score of 00, indicating that R1 has severe cognitive impairment. R1's hospital records prior to readmission [DATE]) documents in part that R1 was seen by a podiatrist in the hospital for a Right Heel Ulceration and documents the following: Plan: Recommend ongoing palliative wound care right heel wound.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to perform wound care in a manner that prevented contamination and failed to follow the wound care facility policy. These failures affected one resident (R1) of three residents reviewed for infection control. R1's face sheet documents in part the following diagnoses: Metabolic encephalopathy, dysphagia, protein-calorie malnutrition, unspecified dementia, cognitive communication deficit, local infection of the skin, cellulitis of the right lower limb, Parkinson's disease, and major depressive disorder. R1's minimum data set (3/11/2026) documents in part a brief interview of mental status (BIMS) summary score of 00, indicating that R1 has severe cognitive impairment. R1's medication review report (3/12/2026) documents that V4 (Podiatrist) gave a written order for Foam boots to feet -- No Pressure, - Dressing (Change) daily gauze and silvadine cream, -daily foot washing; then dressing, - Patient to (return to office) in 2 to 3 weeks.R1's nurse practitioner's progress note (3/19/2026) documents that R1 was treated…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an incident to the nurse causing a delay in care for one resident (R3) out of five residents that sustained a scalp bruise and clavicle fracture. This failure resulted in R3 experiencing pain due to a fracture and bruise which was not treated until the following day.Findings include,Facility's final report to state agency documents in part: Date of incident (10/28/25 at 3:30 pm) (incident was on 10/28/25 at 3:30 am, V2 (Director of Nursing) said it was a typo, the incident happened on the night shift). R3 is alert and oriented to self. During ADL (activities of daily living) rounds, patient was noted with bruising to her left side of her head and left shoulder. She was sent to the ER (emergency room) for further eval where it was determined that she had a Comminuted fracture of the left clavicle, Mild degenerative changes to the left shoulder and a frontal lobe scalp hematoma. Final Summary of investigation: R3 is alert with a BIMS of 00 (Not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-25 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, interviews, and records reviewed the facility failed to follow the menu served to the residents. This failure affected 7 of 7 (R3, R9, R18, R84, R101, R103, and R105) residents receiving pureed diets in a sample of 37 residents. The findings include: On 4/22/25 the Menu listed to be served oven roasted Turkey with Gravy, Sweet Potatoes, Brussel Sprouts, Dinner Roll, Chilled Peaches, and Beverages. On 04/22/25 at 12:00pm the surveyor observing tray service in the kitchen. The surveyor observed the pureed meals served did not receive a bread or roll item on their plate. V9, Cook, said the residents on pureed diet do not have a roll. V10, Dietary Aid, said I can't give them rolls, they puree. On 4/22/25 at 12:03pm V11, Dietary Manager, said we don't do puree bread, we haven't in a long time. V11 said we don't have the bread puree mix. V11 said we have the recipes for the puree bread. Recipe for Pureed Buttered Dinner Roll: ingredients dinner roll, margarine, solids - melted, milk.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to address a resident's and a family's concern about response to call light wait times and failed to allow a resident to have personal refrigerator in at bedside while allowing another resident to have a personal refrigerator at the bedside. This affected two out of three residents (R15, R82) reviewed for resident rights. Findings Include: R15 is an [AGE] year old with the following diagnosis: heart failure, type 2 diabetes, and chronic atrial fibrillation. R82 is an [AGE] year old with the following diagnosis: Alzheimer's disease, dementia, and anorexia. On 04/22/25 at 11:21AM, R15 was interviewed while on the phone with R15's family member (V36). R15 and V36 reported it take 45 minutes or more for staff to answer the call light. R15 and V36 stated they track time on their phones to see how long staff takes to answer the call light. R15 and R36 reported it will take 45 minutes or more to respond to a call light or request about two or 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 follow their Call Light Response policy, by not placing the call light within reach. This affected one of three residents (R321) reviewed for accessible call lights. Finding Include: On 4/22/25 at 12:00pm to 12:08PM, R321 heard yelling Someone Please Help me. Observed R321 in his room, up on a Geri chair, on right side of the bed, foot side area. Call Light on bed, in upper head part of the bed, not within reach of R321. R321 was asking to be put back to bed and voiced out that he is looking for his dentures. On 4/22/25 at 12:10PM, confirmed with V4 (CNA/Restorative Aide) that R321's call light is not within R321's reach. V4 moved and placed the call light closer to R321, and within his reach. On 4/25/24 at 9:00AM, V2 (DON) stated that staff should place the call light within resident's reach. If coming from dialysis, the person placing him in the room should make sure that the call light is within the resident's reach, so they can call for assistance. Call light response policy with a revision date of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to preserve one resident's privacy and dignity and obtain informed consent from the resident and resident's POA (power of attorney) to reside in a semi-private room in which the roommate has constant video monitoring. This failure affected two resident (R71, R77) out of three reviewed for privacy in a sample of 37. Findings include: On 4/22/25 at 10:00 AM, signage was observed on R71 and R77's room doorway noting video monitoring is occurring. On 4/25/25 at 8:30 AM, V1 (administrator) stated that consent is obtained if a roommate is placed in a room with video monitoring. On 4/25/25 at 9:10 AM, V17 (social services) stated that R77's BIMS (brief interview of mental status) is 9 or 10 out of 15. V17 stated that R77 can make her needs known. V17 was questioned regarding reason R77's signature and date do not match from the original document in R77's EMR (electronic medical record) and the copy given to this surveyor. V17 stated that she gave this surveyor the original document of the consent and did not want to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to include intervention prevent or reduce the risk of skin breakdown. for one of three (R1) residents reviewed for plan of care interventions for skin breakdown, failed to follow their policy to complete a comprehensive skin assessment on one resident (R1) with skin impairments on readmission from the hospital to identify the size and appearance of the wounds or dressings present. This failure affected 1 of 4 residents in a sample of 37 residents reviewed for pressure ulcers. The findings include: 1.R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and records the facility failed to follow their policy to complete a comprehensive skin assessment on one resident with skin impairments on readmission from the hospital to identify the size and appearance of the wounds or dressings present, failed to ensue effective interventions were in place, and failed to ensure low air loss mattress was used per manufactures recommendations. This affected two of four residents (R1, R325) reviewed for pressures sore preventions and effective interventions. The findings include: 1. R1's diagnosis includes but are not limited to diabetes, Dementia, Anemia, End Stage Renal Disease, Sacral Pressure Ulcer, Dependence on Renal Dialysis. R1 was admitted to Hospice services on 3/15/25. On 4/24/25 V8 presented the surveyor a care plan labeled original dated 2/3/25 for R1 risk for alteration in skin integrity due to risk factors associated with decreased mobility, poor oral intake, history of pressure ulcers, and advanced age. A second 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 28 citations
  • Potential for harm · D2025-04-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to obtain and document a diagnosis in the physician orders for an indwelling catheter for one resident (R70) out of three reviewed for indwelling catheters in a sample of 37. Findings include: On 4/22/25 at 10:00 AM, R70 was observed to have an indwelling catheter. On 4/25/25 at 8:30 AM, V2 DON (director of nursing) stated that a diagnosis should be documented on the physician order to indicate reason why an indwelling catheter is in place. R70's POS (physician order sheet), dated 3/24/25, notes Indwelling Catheter: _18_Fr,_10cc balloon size for a Diagnosis of _---_. There is no documentation in R70's current POS provided to this surveyor noting reason for indwelling catheter. This facility's physician orders policy, reviewed 3/17/25, notes the elements of an order includes, but not limited to, orders specify the diagnosis or indication for.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to document accurate meal intakes. This affected two of three residents (R12 and R51) reviewed for nutrition in a sample of 37. Findings include: On 4/24/25 at 1:00PM, R12 and R51 were observed in the dining room eating lunch. R12 consumed 25% of meal. R51 consumed 25% of meal. On 4/24/25 at 9:37 AM, V35 RD (registered dietitian) stated that R12 has been losing weight. V35 stated that recently R12's oral intake has decreased. V35 stated that R12 was started on weekly weights to monitor. V35 stated that last week R12 was started on a medication to stimulate R12's appetite and nutrition monitoring currently being followed weekly by the the interdisciplinary team. V35 stated that yesterday V35 saw R51 and observed that R51 was not eating much. V35 stated that yesterday R51 was placed on weekly nutrition monitoring by the interdisciplinary team. V35 stated that staff should be monitoring and documenting the amount eaten at each meal. On 4/24/25 at 1:00 PM, V22 CNA (certified nurse aide) stated that the CNAs are…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their physician services policy and ensure the attending physician conducted face-to-face visits within the first 30 days of admission/re-admission and/or at least once every 60 days. This affected two of three (R12, R51) residents reviewed for care managed by a physician in a sample of 37. Findings include: On 4/25/25 at 8:56 AM, V31 (attending physician) stated that he is present in this facility several times a week. V31 stated that he focuses more on the residents on 2 South nursing unit because this is the acute unit. V31 stated that V31 documents his face-to-face visits with residents in each resident's electronic medical record. R12: R12's medical record notes R12 was admitted to this facility on 5/4/23. R12's medical record notes V33 (attending physician) had face-to-face visit with R12 on 5/24/23. There are no other documented face-to-face visits found in R12's medical record. R12's medical record notes R12 was hospitalized [DATE] -…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0745 — failed to provide medically-related social services — isolated
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    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 assist a resident with a degenerative eye disease in obtaining transportation to an outside retinal specialist appointment. This affected one of one (R27) residents review for transportation in a total sample of 37. Findings Include: R27 is an [AGE] year old with the following diagnosis: macular degeneration. On 4/22/25 at 10:22AM, R27 stated R27 had an appointment for an eye appointment the first week of April but had to cancel it because the cost of transportation was $270. R27 denied being offered to see the in-house eye doctor. R27 reported R27 would be willing to see the in-house eye doctor because R27 wants to preserve R27's vision for as long as possible. On 4/24/25 at 12:15PM,V18 (Health Information Management Director/Appointment Scheduler/Transportation) stated V18 had an appointment on 4/8. V18 reported R27 is now a private pay patient so R27 needs to now pay for transportation to outside appointment. V18 stated social services called a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to follow their policy and complete quarterly psychotropic assessments and assess for or attempt a Gradual Dose Reduction for one resident on an antidepressant. This failure affected one of one (R47) resident in a sample of 37 reviewed for psychotropic medication. The findings include: R1 admitted to the facility on [DATE] with hospitalization and readmissions to the facility since. R1's diagnosis include but are not limited to Multiple Sclerosis and Depression. On 4/24/25 at 12:17PM V3, Assistant Director of Nursing, said she monitors the psychotropic program. V3 said Gradual Drug Reductions (GDR) are attempted or addressed quarterly or if something is going on. V3 said in the electronic charting system there is a Psychotropic Medication Assessment Form for residents on psychotropics, including antidepressants. V3 said the assessment should be assessed quarterly. At 1:23PM V3 said I didn't see one (Psychotropic Assessment) for R47, she should have…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to give prednisolone acetate ophthalmic suspension 1% (steroid eye drop) and Midodrine 5mg tablet (medication that increases blood pressure) as prescribed. This affected two of six resident (R320, R27) reviewed for medication administration in a total sample of 37. Findings Include: R329 is a [AGE] year old with the following diagnosis: hematuria. On 4/23/25 at 8:37AM, V25 (Nurse) took R320's blood pressure and it was 83/39 (low). On 4/23/25 at 9AM, V25 administered all morning medication except Midodrine 5mg tablet. V25 stated medication should be stocked in the pyxis by pharmacy or ordered by the nurse when the medication is low within three to four pills left. V25 reported pharmacy will deliver the medication automatically when it is due to be delivered. V25 called the pharmacy at 9:05AM to ordered the missing medication. V25 stated the medications can be delivered an hour before or an hour after the scheduled time. V25 reported if 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove an expired medication from a medication cart, failed to store two bottles of a medication in a refrigerator that has instructions to store the medication between 36-48 degrees Fahrenheit, and failed to dispose of a controlled medication after it was discontinued during the review for medication storage in a total sample of 37. Findings Include: R3 is a [AGE] year old with the following diagnosis: congestive heart failure and metabolic encephalopathy and on hospice. R38 is a [AGE] year old with the following diagnosis: senile degeneration of the brain and arteriovenous malformation of the digestive system. On 4/23/25 at 9:10AM, the Oak Wing Medication cart on the 2 North unit was reviewed by with V26 (Nurse). During the review, a 12 count card of ferrous sulfate 325mg tablets were in the medication cart with an expiration date of 03/2025. V26 stated medications should be removed from the cart as soon as they expired so there is 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their transmission based precautions policy by two staff not wearing a gown or gloves in a contact isolation room for one resident (R320) reviewed for infection control in a total sample of 37. Findings Include: R329 is a [AGE] year old with the following diagnosis: hematuria. On 4/22/25 at 12:20PM, PPE (Personal Protective Equipment) cart/drawer present by R320's room, signage for Contact Isolation posted at resident's door. V6 (CNA) entered contact isolation room with meal tray. Did not put on PPE. V6 only used surgical mask, and no gloves and no gown, no handwashing observed prior to entering the room. Touched items in the bed side table and placed phone from beside cabinet to overhead table, as per resident's request. Also assisted resident in cutting meal. V6 exited the room and used hand sanitizer. V6 stated that the R320 is new resident, I do not know what kind of isolation R320 is in. V6 also confirmed that V6 did not put…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to follow physician orders to complete a comprehensive metabolic panel for one of three resident (R1) reviewed for physician orders. Findings include: R1 face sheet shows R1 has diagnosis of Ogilvie syndrome, other specified myopathies, muscle wasting and atrophy, dysphagia, severe protein malnutrition, epilepsy syndrome, abdominal pain, cerebral palsy, hypertension, ileus, abdominal distension, constipation, severe intellectual disabilities, megacolon, mood disorder, ileostomy status, acquired absence of digestive tract, pressure ulcer stage 2 buttock, other seizures. R1 physician order sheet with order date of 10/15/24, start date of 10/21/24 denotes CBC W/DIFF (complete blood count and differentials) and platelets, comprehensive metabolic, magnesium, sent uncollected, one time only related to other seizures, Ogilvie's syndrome, cerebral palsy. Order dated 10/16/24 with start date of 10/21/24 denotes CBC W/DIFF and platelets, comprehensive metabolic, sent uncollected, one time only related to one time only related to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to follow Sanitizing Guidelines and Manufacturer's Instructions by not sanitizing a knife and cutting board for 1 minute. This failure has the capacity to affect 104 residents receiving an oral diet at the facility. Findings include: On 5-15-24 at 10:15 AM, surveyor and V11 (Regional Dietary Manager) observed V10 (Cook) sanitize a knife and cutting board by submerging them in the sanitizer in the 3-compartment sink for 1 second. On 5-15-24 at 11:05 AM, V10 (Cook) said cooking items should be sanitized for 1 minute. On 5-15-24 at 10:16 AM, V11 (Regional Dietary Manager) said items should be sanitized for 1 minute in the sanitizer. On 5-15-24 at 11:10 AM, V21 (Dietary Manager) said when using the 3-compartment sink, items should be sanitized for 1 minute. V21 said the manufacturer's guideline says items should be sanitized for at least 60 seconds. V21 said the items are sanitized for 60 seconds to ensure they are properly sanitized and cleaned. Sanitizing Guide documents: Wash, Rinse, and Sanitize equipment and…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-17 · tag F0576 — pattern
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    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 mail was delivered to residents on Saturdays for seven out of seven residents (R5, R11, R21, R40, R53, R76, R80) reviewed for residents' rights in a sample of 26. Findings include: On 05/16/2024 at 11:57 AM during resident council meeting, R5, R11, R21, R40, R53, R76 and R80 all stated that they do not receive mail on Saturdays and have to wait until Monday before it is given to them. On 05/16/2024 at 12:32 PM during interview with V44 (Life Enrichment/Activities), V44 stated that Saturday's mail is being put by the receptionist in her mailbox inside the administration office, which is a locked office. V44 also stated that activity aides do not have access to the administration office. V44 also stated that when she comes in on Mondays, she then distributes the mail to the activity aides to give to the residents. Review of facility's document entitled Contract Between Resident and Facility Attachment F: Statement of Resident Rights indicated: No resident should be deprived of any rights, benefits, or privileges…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to notify family of a resident's change of condition for one of three residents (R251) reviewed for notification of change in a sample of 26. Findings include: On 05/15/2024 at 8:37AM during interview with V39 (R251's family member), V39 stated that on 02/03/2023, R251 was sent to the hospital and V39 was not informed. On 05/16/2024 at 2:38PM during interview with V2 (Director of Nursing), V2 stated that it is expected for staff to notify the family of any change of condition of the residents' even in case of emergency. Review of R251's progress notes and assessments from 02/01/2023 to 02/05/2023 did not indicate any notification made to V39. Review of facility's policy entitled Change in Resident Condition reviewed on 1/10/2024 indicated the following: Policy: 3. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure one resident identified as at risk for abuse was free from misappropriation of resident property by not providing a secure location for R86 to store his money. This affected one of three (R86) residents reviewed for misappropriation of funds. This failure resulted in R86 having four hundred dollars stolen while he was in the facility. This failure affected 1 of 3 reviewed for misappropriation of resident's funds in a total sample of 26. Findings Include: R86 was diagnosed with aphasia following a cerebral infraction. Minimal data set section C (Brief interview for mental status) dated 2/23/24 documents: memory/recall ability: resident (R86) was normally able to recall location of own room, staff names/faces and that they are in a nursing home/hospital swing bed. Cognitive skill for daily decision making documents: modified independence: some difficulty in new situation only. Section B (Hearing, Speech and Vision documents: Speech Clarity: unclear speech. Ability to express ideas and wants: sometimes understood:…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy by not immediately reporting a bruise of unknown origin to the immediate supervisor or the administrator. This affected one of three (R17) reviewed for injury of unknow origin in a total sample of 26. Findings include: R17 was admitted to the facility on [DATE] with a diagnosis of hypertension, depressive disorder, hemiplegia and respiratory failure. R17's progress note dated 4/19/24 documents by V25(Nurse): Patient sister reported to me that her sister had a bruise on her hand and states it was caused by a staff member. Patient interviewed and skin assessment completed, noted a bruise to her right hand. Patient states that while being changed by staff, staff member dug her long fingernails into patient while turning her. When patient said that hurts the staff member said I'll show you what hurts and squeezed her hand causing a bruise. She was unable to tell me the days or the staff member who did it. Administration notified…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-30 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to ensure that staff working followed the standard of care during a code blue by establishing an airway and turning on the oxygen tank to provide needed oxygen. This affected one of three residents (R4) reviewed for oxygen use during a code blue. Findings include: On [DATE] at 12:51PM V2, Registered Nurse (RN), said V4, LPN, was assessing R4's vital signs. V2 said I suctioned R4 and it was clear. V2 said R4 was receiving continuous oxygen. V4 said I immediately suctioned R4 because she may have a blockage that causes shortness of breath. V2 said I was not trained at the facility on tracheostomy (trach) care. During a follow up interview V2 reported each step she took when she entered R4's room. V2 said she attempted to suction R4. V2 said nothing came out, not even blood. V2 said we started Cardiopulmonary Resuscitation (CPR) on R4 and attached the resuscitation bag and oxygen at 100%. (V2 did not say she removed R4's inner trach cannula during this…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow physician orders and administer phenobarbital (Anti-Seizure) as ordered. This failure affected one of three (R2) reviewed for physician orders. This failure resulted in R2 missing 7 scheduled doses of phenobarbital, subsequently developing seizures activities requiring R2 to be sent the local hospital for treatment of seizures. Findings include: R2 face sheet shows diagnosis of unspecified convulsions, personal history of traumatic hydrocephalus. R2 progress notes dated 11/21/23 denotes in part during rounds at 4:30A.M. resident was observed actively seizing. Lasted approximately 2 minutes from when he was found and when it stopped. Physician was notified. Order to send pt (patient) to ER for evaluation. Noted and carried out. Spoke with POA (power of attorney) agreed with plan. Call placed to 911. Resident was p/u (picked up) by paramedics and taken to Hospital. All necessary paperwork was sent with him. ADON (Assistant Director of Nursing) was made aware. On 1/3/23 at 2:30pm V16 (RN) said she worked…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records reviewed the facility failed to follow their policy and plan of care, by not repositioning a cognitively impaired, incontinent, and dependent resident with a stage 3 buttock pressure ulcer for over 2 hours. This failure affected one of three residents reviewed for pressure sore prevention nterventions. findings includes R1 has diagnosis including but not limited to Displaced Fracture of Seventh Cervical Vertebra, Difficulty in Walking, Fracture of Neck, Dysphagia, Cerebral Infarction, Hypertension, Dementia, and Depression. R1's cognitive assessment dated [DATE] indicates R1 is severely impaired. R1's bowel and bladder assessment dated [DATE] states R1 is always incontinent of urine. R1's functional status states she requires extensive assistance with bed mobility, dressing, and personal hygiene. R1 is total dependent on staff for toileting assistance. On 9/5/23 at 11:30AM observation of R1 started. R1 sitting in the dining room across from nurses' station in a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-02-24 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to have an (IP) Infection Preventionist with the required specialized Infection Prevention Control training beyond the initial professional training and education. This failure has the potential to affect all 98 residents listed on the facility census. Findings Include: On 2/22/23 at 3:30 PM V22 (Infection Preventionist) said I took the IP training that was recommended by corporate. It was Infection Control training. That was all the IP training that I have completed. The facility presented a certificate from InfectionControlsTraining.com for V22. The certificate indicates that the course included Introduction to Infection Control, Transmission, Prevention and Control, Hand Hygiene, Personal Protective Equipment, Environmental Controls, Sharps and Injection Safety, Occupational Health and Safety, Sepsis for a total of 4.0 Credit Hours. Policy: Infection Preventionist Date 11/2019 3. The Infection Preventionist will have completed specialized training in infection prevention/control (Nursing Home Infection Preventionist…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-24 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure 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 that medication was administered as ordered by the physician for 4 of 4 residents (R15, R35, R56, R200) and facility failed to prevent significant medication errors for 1 of 4 residents (R56) reviewed for medications in a sample of 25. Findings include: On 2/21/2023 at 11:10am V7(Registered Nurse-RN) was observed administering medication to R15. On 2/21/2023 at 11:12am V7 said these are 9am medications, I am behind they should be administered one hour before or one hour after, these are an hour and ten minutes late. On 2/23/2023 at 1:00pm V2 (Director of Nursing-DON) said medication can be administered one hour before and one hour after the time the physician prescribed. If a nurse is late administering medication, I expect the nurse to call the physician and monitor the resident. An Order Summary Report dated 2/23/2023 indicated that R15 has medication due at 9am- Amlodipine 5mg-1 tab, Lexapro 10mg-1 tab, lisinopril 5milligram(mg)-1 tab(tablet), Ursodiol 300mg-1cap, Vitamin D3 25micrograms(mcg)-1 tab,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure dignity was maintained by not providing incontinence care in a timely manner for 1 of 4 residents (R13), the facility also failed to ensure a privacy bag was provided for urinary catheters for 2 of 2 resident (R70, R89) reviewed for resident's rights in a sample of 25. Findings include: 1. On 2/21/2023 at 10:20am R70 was observed in bed with family members in the room with the urine collection bag exposed. On 2/21/2023 at 10:22am V10(Family Member) said why is her urine bag exposed, I don't want to look at that, should it be amber in color. On 2/21/2023 at 10:30am V7(Registered Nurse-RN) said the urine collection bag should be covered with a privacy bag. On 2/23/2023 at 1:00pm V2(Director of Nursing-DON) I expect all urine collection bags to be covered for privacy. An Order Summary Report indicates that R70 has an order dated for 2/11/2023 for an indwelling catheter. 2. On 2/21/2023 at 10:33am R13 was observed in bed with the call light on, R13 said I have had my call light on for 30 minutes and no one…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 that the call light was within reach for two residents (R30 and R82) reviewed for call light in a sample of 25. Findings include: On 2/21/23 through 2/23/23 at 10:30 am during a tour of the facility, R30 was observed in bed with the call light laying on the floor. During an interview on 2/21/23 at 11:00 am, V11 (Restorative Nurse) stated that the call light should be within R30's reach. During an interview on 2/22/23 at 11:15 am, V2 (DON) stated that all call lights should be within the resident's reach. Resident admitted on [DATE] with Normal Pressure Hydrocephalus, Cerebral Ischemic Attack, and Degenerative Disease of the Nervous System. Resident oriented to self and environment. Facility policy dated 10.2021 reads; General: To Provide the staff with guidance on responding to resident's request and needs. Procedure: 5. When the patient or residents is in bed or confined to bed or chair, provide the call light within easy reach of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide the prescribed wound treatment for one (R92) of one resident reviewed for other skin conditions in a sample of 25. Findings include: On 02/21/2023 at 10:49AM, R92 stated that the dressing on his buttocks is not being changed daily. On 02/22/2023 at 11:10AM, V15 (Registered Nurse) stated that treatments are done by the wound care nurse from corporate office and on weekends the nurses do it. On 02/22/2023 at 11:30AM, V14 (Wound Care Nurse) stated that she comes in once in a while but not regularly. On 02/22/2023 at 11:30AM, V29 (Wound Care Nurse) said that she was asked to come from another facility to this facility just for Wednesday (02/22/2023) and Thursday (02/23/2023). On 02/23/2023 at 1:35PM, TARs of R89 and R92 were observed with V2 (Director of Nursing) and stated that blank spaces indicates that the treatment was not done. She also said that wound treatments are expected to be done as ordered. She added that wound care are done by nurses if the wound care nurse is not in the building. R92's Treatment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide the prescribed pressure ulcer treatment for one (R89) of one resident reviewed for pressure ulcer in a sample of 25. Findings include: On 02/23/2023 during record review, R89 was noted to have antibiotic orders for a left buttock ulcer. Treatment administration record (TAR) was observed with multiple blank spaces on signature lines for treatment on left buttocks for January and February 2023. On 02/22/2023 at 11:10AM, V15 (Registered Nurse) stated that treatments are done by wound care nurse from corporate office and on weekends the nurses do it. On 02/22/2023 at 11:30AM, V14 (Wound Care Nurse) stated that she comes in once in a while but not regularly. On 02/22/2023 at 11:30AM, V29 (Wound Care Nurse) said that she was asked to come from another facility to this facility just for Wednesday (02/22/2023) and Thursday (02/23/2023). On 02/23/2023 at 1:35PM, TARs of R89 and R92 were observed with V2 (Director of Nursing) and stated that blank spaces indicates that the treatment was not done. She also said that wound…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 apply a splint to prevent contractures on one resident (R82) out of one resident reviewed for splints in the sample of 25. Findings Include: On 02/21/23 at 3:15 PM, surveyor observed R82 with V4 (Director of Therapy). V4 asked R82 to open his right hand which was a closed fist, but he could not. V4 assisted R82 to open his right hand. V4 said that it was not been brought to her attention that R82 cannot open his right hand by himself. On 12/22/2023 at 10:49 AM, V11 (Restorative Nurse) said that she was aware that R82 cannot open his hand by himself. V11 said that R82 is on range of motion, and bed mobility program. V11 said that a hand splint to prevent contractures should have been ordered before yesterday 2/22/2023 and that it was initiated. On 02/23/2023 at 11: 06 AM, V12 (Restorative Aide) said that she does range of motion. Said that the resident should have a hand protector to prevent contractures. Also, that staff should make sure…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 handle oxygen safely for one (R7) of one resident observed for oxygen therapy in a sample of 25. Findings include: On 02/21/2023 at 10:40AM during observation, R7 was observed with nasal cannula connected to oxygen concentrator. The tubing and humidifier were observed undated. On 02/21/2023 at 1:04PM, R7 was observed with V15 (Registered Nurse) and noted nasal cannula tubing undated. She said that oxygen tubing and humidifiers should be changed weekly and dated. On 02/23/2023 at 1:35PM, V2 (Director of Nursing) stated that all nasal cannula tubing are expected to be dated, and changed weekly and as needed. R7's order summary report indicated admission date of 2/2/23, diagnoses of but not limited to lobar pneumonia and chronic obstructive pulmonary disease, and order for oxygen at 3-4 liters per minute per nasal cannula (NC). Facility Policy: Title: Oxygen Administration Date Created: 7/2022 Infection Control Issues: 2. The oxygen delivery device (e.g., nasal cannula, mask) will be changed once a week or as…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors related to antibiotic administration for 1 of 4 residents (R56) reviewed for medication administration. Finding include: On 2/21/2023 at 11:38am V7(Registered Nurse-RN) said these are R56's, 9am medications and they are late by one hour and thirty-eight minutes they should be one hour before and one hour after, she also has antibiotic due at 9am for a tooth extraction. On 2/23/2023 at 1:00pm said V2(Director of Nursing-DON) said if a resident receives an antibiotic after the time, then I expect the nurse to notify the physician and monitor for side effects. I thought she called the physician before giving the next dose of antibiotic which was due at 1:00pm. An Order Summary report dated 2/23/2023 indicates that R56 has medication to be administered at 9am and 1pm and 7pm. Acidophilus 1 capsule, Calcium 600mg-1tab, fish oil 1000mg-1cap, vitamin C- 500mg-1 tab, Multivitamin with mineral-1tab, potassium 20 millequivalent-1tab, amlodipine 5mg-held,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to implement appropriate transmission-based precautions for two (R88, R147) of two residents observed for transmission-based precautions in a sample of 25. Findings include: On 02/21/2023 at 11:00AM during observation, outside R88's room was a sign that reads as Contact Precautions. V16 (family member) was observed inside R88's room not wearing gown and gloves. On 02/22/2023 at 2:30PM during observation, V17, V18 and V19 (family members) were all observed inside R88's room not wearing gown and gloves. On 02/22/2023 at 2:30PM, V17, V18 and V19 stated that they all came in the room without gown and gloves because the staff came in with them for the care plan meeting without putting any on. On 02/23/2023 at 1:35PM, V2 (Director of Nursing) said that all staff and visitors are expected to wear gown and gloves before going inside the room of a resident on Contact Precautions. R88's order summary report indicated admission date of 2/9/23, diagnosis of but not limited to methicillin resistant staphylococcus aureus…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-01-30 · tag F0586 — pattern
    Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to ensure census reports were accurate when notifying an external entity (Age Options) of new admission to the facility, discharges out of the facility, and death of residents. This failure affected 7 residents reviewed in a sample of 98 residents. Findings include: On [DATE] at 10:20AM V12, Age Options Worker, said without the facility report the program can not help the residents. V12 said she spoke with the Organization Monitor and was told to contact IDPH. On [DATE] at 11:34AM V11, Admissions Director, demonstrated the Maximus/Pathtracker system for the surveyor. V11 said when a resident comes in, I enter their name and Medicaid number, if they have one or the social security number. V11 said when they leave, I enter the date they leave the facility. At 12:43PM said we will go in a few time a week to update in Maximus. V11 said I will update with changes within a few days, about 3 days. V11 said I last updated on Saturday [DATE]. On [DATE] at…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$327,435 in federal fines across 4 penalties. 2 Medicare payment denials on record.

  • $50,980 — penalty dated 2025-07-31
  • $20,426 — penalty dated 2025-04-25
  • $152,425 — penalty dated 2024-05-17
  • $103,604 — penalty dated 2024-01-30
  • Medicare payment denial — starting 2025-08-21 for 22 days
  • Medicare payment denial — starting 2024-06-06 for 44 days

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

Part of a chain

This home belongs to ALIYA HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.0-1.0 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 1 of 51.4-0.4 vs chain
Quality measures 4 of 53.8+0.2 vs chain
The other 13 homes this chain runs (chain average 2.0★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
ALIYA FIVE HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 08/01/2023
ALIYA FIVE MEMBER A LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST12%since 08/01/2023
HAVEN CAPITAL LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 08/01/2023
OPTIMUMBANKOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 09/20/2023
WEINFELD, EFRIAMIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2023
KRIEPS, JAMIEIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2023
GAUTAM, SAGUNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2023
KOWALCZYK, JOSEPHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2023
ERLICH, MOSHEIndividualADP OF THE SNFsince 08/01/2023
REIFER, JORDANIndividualADP OF THE SNFsince 08/01/2023
WEINFELD, AVRUMIndividualADP OF THE SNFsince 08/01/2023

CMS files one row per role, so the 20 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$7.7M
Net patient revenuemost recent cost report
-2.0%
Operating marginrevenue minus expenses
$278K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 38%Medicare 22%Other / private 40%

This home reported $278K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$396per resident / day
operating cost
$12,030per month
≈ monthly operating cost
$388per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146053. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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