Sharon Health Care Pines

Location & what’s nearby

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

Quality measures — how residents actually fare

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

Staffing

How full it usually is: this home is certified for 116 beds and averages 107.8 residents a day — about 93% occupied, or roughly 8 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the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026.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 2.77 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.35 hrs/resident/day on weekends vs 2.95 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.33 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

43 citations, most serious first. The 20 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to initiate and implement safety interventions for a resident who was on a restricted pass due to impaired thought process and poor safety awareness to prevent an elopement, failed to ensure staff were educated on identifying residents with restricted passes to leave the facility, failed to assess a resident after elopement, and failed to educate staff or implement additional safety interventions once a resident eloped for three (R37, R72, and R75) of four residents reviewed for elopement. These failures resulted in R75, who the facility identified as not being capable of unsupervised outside pass privileges due to poor safety awareness, impaired thought process, and psychiatric diagnoses (including Schizophrenia), from exiting the facility without staff knowledge or supervision on 8/24/25 when R75 left the grounds in a Taxi. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8-24-25 when R75 left the Facility…

  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
• Immediate jeopardy · Lcited before2025-04-24 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to protect a resident (R1) from mental and verbal abuse and failed to protect residents from further potential abuse. This failure resulted in residents experiencing emotional distress and persistent fear of V3 (Certified Nursing Assistant). This failure has the potential to affect all 102 residents who reside in the facility. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/19/25 at approximately 5:00 pm, when V3 (Certified Nursing Assistant/CNA) responded inappropriately to R1. V3 taunted R1 by sticking her tongue out at R1; calling R1's significant other ugly; and asking if R1 was going to fight V3. R1 experienced emotional distress and fear of V3. V3's termination was rescinded and V3 returned to work in the facility, leaving residents fearful. While the immediacy was removed on 4/24/25, the facility remains out of compliance at Severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-05-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to protect a vulnerable resident (R1) who is known to become agitated with loud noises and too much stimulation, from being a victim of resident-to-resident abuse on 4/7/2024 and 4/11/2024 and failed to maintain the intervention of 15-minute monitoring for (R1). These failures resulted in an Immediate Jeopardy starting 4/7/2024. While the Immediate Jeopardy was removed on 5/2/2024, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits Findings Include: The facility's Abuse Prevention Program Facility Policy, reviewed 11/10/2023, documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-06-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to prevent abuse of five (R2, R4, R5, R6, R7) of 7 residents reviewed for abuse. This failure resulted in R1 picking up a chair and hitting R2 in the head causing R2 to go unconscious, sustaining a bleeding laceration to upper lip requiring sutures and sustaining a laceration to left side of head requiring three staples. Findings include:The facility policy, Abuse Prevention Program Facility Procedure, reviewed 9/1/25, documents not in its entirety, This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment.1. Facility incident report dated 5/24/26 documents that R1 and R2 got into a physical altercation after R2 became agitated at R1 over table seating in the dining room. R1 asked R2 to go to another table causing R2 to strike out at R1 and R1 picking up a chair and hitting R2 in the head causing R2 to go unconscious 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview, the facility failed to protect a resident from physical abuse for two of four (R1 and R3) residents reviewed for abuse in a sample of four. This failure resulted in R1 sustaining a complex fracture of the left hip requiring surgical intervention. Findings include:The facility's Abuse Prevention Program, reviewed 7/21/25, documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This form also documents that willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.R1's electronic medical record documents the following diagnoses: Schizophrenia, Major Depression, Dementia, EPS, HTN,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to prevent resident-to-resident physical and sexual abuse and failed to implement abuse risk assessment and care plans for four of four residents (R1-R4) reviewed for abuse in a sample of four. This failure resulted in R1 sustaining a left femoral neck fracture, requiring surgical intervention. Findings include: The Abuse Prevention Program Facility Policy, revised 12/18/24, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This form also documents that abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Instances of abuse of all residents, irrespective of a mental or physical condition, cause physical harm, pain, or mental anguish. This form documents that physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from physical abuse by another resident (R1) for two of four residents reviewed for abuse in a sample of four. This failure resulted in R2 receiving sutures at the hospital for a facial laceration. Findings include: The facility's undated Abuse Prevention Program Facility Policy documents Policy: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This policy continues to state, This facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, other residents,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure two (R1 and R6) of four residents were free from abuse in a sample of eight. These failures resulted in R1 and R6 both going to the hospital after R1 was struck in the head, and R6 getting a bloody nose. Findings include: Facility Abuse Prevention Program Facility Policy, reviewed 9/26/23, documents This facility affirms the right of our residents to be free from abuse. Abuse means any physical or mental injury or sexual assault inflicted upon a resident. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 1. Facility reported incident, dated 10/7/23 documents R1 and R2 got in a verbal altercation, yelling at one another, R2 swung at R1, and both began pulling each other's…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-15 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident (R2), for one of three residents (R1), reviewed for abuse, in a sample of five. Due to the physical abuse R1 experienced an abrasion to R (right) hand knuckles, skin tear to bridge of nose and laceration to L (Left) cheek. FINDINGS INCLUDE: The facility policy, Abuse Prevention and Reporting, dated (reviewed 7/11/23) directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. R1's Nursing Progress Notes, dated 8/1/2023 at 6:30 P.M. document, (R1) got in a physical altercation with peer (R2) at the smoking patio. Abrasion to R (right) hand knuckles, skin tear…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-06-22 · tag F0770 — failed to provide lab services — isolated
  Provide timely, quality laboratory services/tests to meet the needs of residents.
  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 obtain a physician ordered Dilantin level for one of two residents (R47) reviewed for hospitalizations in the sample of 30. This failure resulted in R47 being hospitalized with a critically high Dilantin level. Findings include: On 06/20/23 at 10:41 AM, R47 was alert self-propelling himself in the hallway. R47 stated, A few weeks ago, I had to go to the hospital because they messed something up with my medicine. R47's Care plan, dated 6/21/23, documents, (R47) has a seizure disorder. (R47) has a (vagal nerve) Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness. Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. R47's Nurses' notes, dated 4/15/23 at 10:23 a.m., document, This nurse was notified that (R47) was out on the patio having a seizure. (R47) was having a seizure for 4 minutes. No falls or no injuries. (R47) stayed in a catatonic state for 15 minutes. Doctor was notified and his orders are 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-25 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to report a resident-to-resident abuse allegation to the state agency for one (R1) of seven residents reviewed for abuse. Findings include:Facility policy, Abuse Prevention Program Facility Procedures, reviewed 9/1/25, documents not in its entirety, Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has occurred, the resident's representative and the Department of Public Health's regional office shall be informed by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported and is being investigated. The report shall include the following information, if known at the time of the report: Name, age, diagnosis and mental status of the resident allegedly abused, neglected, exploited, mistreated, or from whom property was misappropriated, type of abuse reported (physical, sexual, neglect, verbal or mental abuse,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent abuse for one (R2) of three residents reviewed for abuse in a total sample of ten.The facility's Abuse Prevention Program Policy revised 12/18/24 documents that the facility affirms the right of our residents to be free from abuse.R2's medical record documents R2 was admitted to the facility on [DATE] with diagnoses to include Alcohol Abuse, Diabetes, Anxiety Disorder, and Psychoactive Substance Abuse.R2's Nursing Progress Note dated 1/18/26 at 12:21 PM documents Resident in a physical altercation with peer, resident separated by staff, no injuries noted.R2's Brief Interview for Mental Status dated 3/10/26 documents a score of 14, indicating R2 has little or no or little cognitive impairment. R3's medical record documents R3 was admitted to the facility on [DATE] with diagnoses to include Obsessive-Compulsive Disorder, Ischemic Heart Disease, Mood Disorder with Manic Features, and Encephalopathy.R3's Nursing Progress Note dated…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-03 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure there are sufficient number of licensed nursing staff to provide care and supervision for dependent residents. This has the potential to affect all 110 residents residing in the facility. Findings include: The facility's Staffing Policy, dated 4/30/25, documents, It is the policy of the facility that minimum numbers of nursing staff members within the facility be established and maintained. Staffing levels may vary by shift and by the day of the week and should be based on census, and level of care needed/medical acuity of the in-house resident population.The facility Staffing Requirements calculators, dated 8/5/25, 8/12/25, 8/16/25, 8/17/25, 8/23/25, 8/24/25, documents the number of licensed nursing staff required for day shift (7:00 a.m. to 3:00 p.m.) was four nurses/32 licensed nursing hours, for evening shift (3:00 p.m. to 11:00 p.m.) three nurses/24 licensed nursing hours, and for night shift (11:00 p.m. to 7:00 a.m.) two nurses/16 licensed nursing hours.On 8/28/25 at 8:30 AM, V2 (Director of Nursing) provided…

  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 · F2025-09-03 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview the facility failed to ensure a Registered Nurse was working eight consecutive hours in a twenty four hour period. This has the potential to affect all 110 residents residing in the facility. On 8/28/25 at 8:30 AM, V2 (Director of Nursing) provided all nurse timecard reports for 8/5/25 through 8/24/25. The timecard reports have no documentation of a registered nurse working eight consecutive hours on 8/12/25. On 08/28/2025 at 10:15 AM, V2 confirmed there was not a Registered Nurse working on 8/12/25.The facility's Center's for Medicare and Medicaid Services Long Term Care Application, dated 8/25/25 and signed by V1 (Administrator), documents there are 110 residents residing in the facility.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-03 · 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 label, and date opened food items in the kitchen's refrigerator and freezer and discard expired food, ensure kitchen ceiling tiles/vents were kept clean, and ensure kitchen freezer was maintaining proper temperature. This failure has the potential to affect all 110 residents. Findings include:The facility's Labeling and Dating and Food Policy, dated 4/25/25, documents Purpose: To prevent foodborne illness and ensure safe storage, handling, and consumption of all foods served to resident by clearly labeling and dating all food items upon receipt, preparation, or opening, in accordance will Illinois state regulations and facility policies. This policy applies to: All dietary services staff, caregivers, and any staff handling food. All food items stored in the main kitchen, refrigerators, freezers, pantries, meal prep areas, and resident rooms (as applicable). Definitions: Label: A written or printed tag or marker attached to or placed on a food item that identifies the item, date opened, and any other required…

  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 · F2025-09-03 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview the facility failed to ensure the facility maintained an effective pest control program. This has the potential to affect all 110 residents. Findings include:The facility's Pest Control Policy, dated 4/25/25, documents Purpose: Ensure a safe, healthy, and comfortable living, environment for residents, staff, visitors, and guests by managed and preventing pest infestations. 2. Scope: Applies to all buildings and grounds owned, leased, or operated by the facility, including resident rooms, common areas, kitchens, dining areas, laundry, maintenance spaces, and storage areas. Covers all staff, contractors, vendors, volunteers, residents, and visitors. 3. Definitions: Pest: Any unwanted animal (insects, rodents, birds, etcetera) or related hazard affecting health, sanitation, and comfort. Integrated Pest Management: A holistic approach combining prevention, monitoring, sanitation, exclusion, mechanical and cultural controls, and limited, targeted use of pesticides as a last resort. 5. Policy Statements: Prevention and Sanitation: Maintain high standards…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-03 · tag F0944 — widespread
  Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and interview the facility failed to ensure all staff received annual QAPI (Quality Assurance and Performance Improvement) in-service training. This failure has the potential to affect all 110 residents residing within the facility. Findings include:The facility's Center's for Medicare and Medicaid Services Long Term Care Application dated 8/25/25 and signed by V1 (Administrator), documents there are 110 residents residing in the facility. The facility's List of Staff In-services, dated 8/8/24 through 8/25/25, do not include documentation of facility staff receiving annual QAPI training.On 8/28/25 at 12:55 PM V21/Administrative Assistant verified no staff at the facility has received the annual QAPI training.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-03 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to document medications at the time of administration for nine of nine residents (R3, R4, R6, R8, R13, R15, R18, R61 and R89), reviewed for medication administration, in a sample of 40. FINDINGS INCLUDE: The (undated) facility policy, Medication Administration directs staff, Documentation: Initial Medication Administration Record immediately after administering medications. No pre-signing or post-signing. A review of R4's current Medication Administration Record, dated August 2025 includes the following medications Aspirin 81 MG (milligrams), Escitalopram 15 MG, Fenofibrate 200 MG, Fluticasone Inhalation Aerosol, Incuse Ellipta Inhalation Aerosol 62.5 Mcg/ACT, Loratadine 10 MG, Omeprazole 20 MG, Oxybutynin Extended Release 10 MG, Albuterol Sulfate Inhalation 108 MCG/ACT 2, Eliquis 5 MG, Hydroxyzine 25 MG, Lasix 40 MG, Metformin 1000 MG, Risperidone 1 MG, Divalproex Delayed Release Sprinkle 125 MG and Pregabalin Oral Capsule 100 MG, not documented as administered 10+ times from August 1- August 25, 2025. A review…

  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 · D2025-09-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation, and record review, the facility failed to provide physician ordered treatments to one of one resident (R108) reviewed for skin conditions in the sample of 40. Findings include: On 8/25/25 at 10:41 AM, R108 had multiple round, red, raised, and flaky areas scattered throughout his bilateral upper and lower extremities. R108 stated the areas are psoriasis and eczema. R108 also stated the areas have gotten worse recently. R108's care plan, dated 8/14/25, documents R108 has psoriasis on his body and interventions to apply Nystatin powder to abdominal folds as ordered and triamcinolone as ordered. R108's physician's order, dated 8/26/25, documents R108 has the following orders: triamcinolone acetonide external cream 0.1 % apply to R108's affected area topically two times a day every Monday, Tuesday, Wednesday, Thursday, Friday for diagnosis of psoriasis ordered 8/22/25; antifungal powder apply to R108's abdominal fold topically three times a day for excoriation ordered 7/5/23. R108's MAR (Medication Administration Record), dated August 2025 documents as 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-03 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  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, record review and interview, the facility failed to give medications as ordered by the physician to three residents (R4, R8 and R18) of eleven residents reviewed for medication pass. This failure resulted in three errors out of twenty-five opportunities for a 12% medication error rate.FINDINGS INCLUDE:The (undated) facility policy, Medication Administration directs staff, Follow the seven rights- right patient, right medication, right dose, right time, right route, right documentation and right to be informed. Medication Preparation: Follow special directions: Shake Well, Do Not Crush, etc. Medication Errors: Manufacturer specifications/Professional Standards: Failure to Shake Well. Inhalers should be given with 1 minute between puffs of the same med and 5 minutes between puffs of different medications. Metered dose inhalers should be shaken well, and resident instructed on correct technique. 1. R4's current Physician Order Sheet, dated [DATE] includes the following medication: Albuterol…

  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

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

Fines & penalties

$235,100 in federal fines across 2 penalties.

• $80,600 — penalty dated 2025-04-24
• $154,500 — penalty dated 2024-05-02

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

Who owns this facility

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

What families pay in IL