Landmark Of Richton Park Rehab & Nsg Ctr

22660 South Cicero Avenue, Richton Park, IL 60471 · For profit - Limited Liability company · 294 certified beds · (708) 747-6120 Medicare & Medicaid certified

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Flagged for abuse14 actual-harm citations$548,244 in federal fines3 Medicare payment denials

Insights

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

Worth asking about

CMS has flagged it for abuse
it has abuse, neglect, or exploitation citations (F0600, F0604) — most recent Dec 2025
it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
it has 14 actual-harm citations
a high number of inspection citations overall (70) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
the CMS record shows $548,244 in federal fines (most recent 2026-05-15)
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

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

Hospital

FRANCISCAN HEALTH OLYMPIA & CHICAGO HEIGHTS3.6 mi

★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7

Urgent care / clinic

Dorothy Anoina MD0.8 mi

4511 Sauk Trl · (708) 283-0376 · Call to confirm hours

Pharmacy

Walgreens0.7 mi

4889 Sauk Trl · (708) 679-0598 · Call to confirm hours

Grocery

Walmart Grocery Pickup and Delivery1.1 mi

22401 Central Avenue · (708) 552-7172 · Call to confirm hours

Park

Pierce Park0.3 mi

22675 Latonia Ln · Typically dawn to dusk

Place of worship

Acme Baptist Church0.6 mi

5219 Deana Ln · (708) 679-0560

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	4 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

Measure	This home	State avg	Typical state	vs typical state
Long-stay residents whose need for help with daily activities increased	5.4%	13.4%	15.4%	better
Long-stay residents who lose too much weight	6.2%	6.3%	5.4%	worse
Long-stay residents with a catheter left in their bladder	0.5%	0.9%	0.9%	better
Long-stay residents with a urinary tract infection	0.0%	1.5%	2.0%	better
Long-stay residents with depressive symptoms	91.5%	54.2%	6.5%	worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained	0.0%	0.1%	0.1%	better
Long-stay residents with falls causing major injury	0.7%	3.1%	3.3%	better
Long-stay residents whose ability to walk worsened	2.9%	14.3%	16.1%	better
Long-stay residents on antianxiety or hypnotic medication	8.0%	18.3%	18.9%	better
Long-stay residents given the seasonal flu vaccine	76.5%	91.8%	95.3%	worse
Long-stay residents with pressure ulcers	15.5%	4.8%	4.7%	worse
Long-stay residents with worsening bladder/bowel control	8.5%	20.6%	21.2%	better
Long-stay residents who got an antipsychotic medication — see the note below the table	44.8%	21.7%	17.1%	worse
Short-stay residents who newly got an antipsychotic medication	0.0%	2.2%	1.4%	better
Short-stay residents rehospitalized after admission	19.7%	26.1%	22.6%	better
Short-stay residents with an outpatient ER visit	2.9%	13.9%	12.0%	better
Long-stay hospitalizations per 1,000 resident days	2.17	2.02	1.67	worse
Long-stay outpatient ER visits per 1,000 resident days	1.88	2.22	1.80	typical

‡ 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.

0.18U.S. median 0.31

Therapy hours / resident / day

0.10hours / resident / day

Physical therapy

0.05hours / resident / day

Occupational therapy

0.04hours / resident / day

Speech therapy

Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 57% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home

Measure	This home	CMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.	—
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs	not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.53

RN hours/ resident / day

0.65

LPN hours/ resident / day

1.40

Aide hours/ resident / day

2.58

Total nurse hours/ resident / day

0.45

RN hoursweekends

54.2%

Total nursing turnover

52.6%

RN turnover

How full it usually is: this home is certified for 294 beds and averages 106.9 residents a day — about 36% occupied, or roughly 187 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.58 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.40 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 2.23 hrs/resident/day on weekends vs 2.72 on weekdays — 18% thinner on weekends. RN hours go from 0.57 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

10 ↓

deficiencies at the latest standard inspection (2025-03-07)

at the previous standard inspection (2024-05-03)

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

Inspection deficiencies

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

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.

70 citations, most serious first. The 24 most serious are shown; the remaining 46 are one tap away and print in full.

Actual harm · Gcited before2026-02-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a resident with services to avoid emotional distress and anguish by failing to assist a post-op patient with follow-up appointment, failed to ensure that resident was receiving therapy as ordered and failed to ensure that staff assist the resident with activities of daily living (ADL). These failures affected one (R3) of four residents reviewed for quality of care. As a result, R3 developed increased swelling, increased pain and blood clot to his right hip and stated that he feels hopeless since being admitted because he thinks nobody cares about his pain and healing process.Findings include:R3 is a [AGE] year-old male admitted to the facility on [DATE] post open reduction and internal fixation (ORIF 1/16/2026), past medical history includes fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing, person injured in unspecified motor vehicle accident, anemia, anxiety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Actual harm · G2026-02-18 · tag F0697 — failed to manage pain — isolated
Provide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review, the facility failed to manage post-op pain for one resident (R3) by failing to administer pain medications (Oxycodone and Tylenol) as ordered, failed to monitor and document effectiveness of pain relief, and failed to use non-pharmacological interventions as part of the pain control regimen as care planned. This failure affected one (R3) of four residents reviewed for pain management. These failures contributed to R3 suffering psychological harm and feeling a sense of hopeless because no one cared about his pain or healing and pain rated 10 on a scale of 1-10.Findings include: On 2/1/2026 11:00AM, R3 was observed in his room, awake and alert, said that facility is not controlling his pain and not getting his pain medication orders straight, they told him he does not have an order for oxycodone, but was clearly listed in his discharge summary that was provided to the facility. Resident rated his pain as 10 on a scale of 1 to 10.Face sheet documented the following…
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 beforedisputed · IDR2025-09-08 · 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 upon interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to obtain physician orders for blood glucose monitoring/sliding scale insulin, failed to receive blood glucose parameters for physician notification, failed to follow physician orders, failed to ensure that medication was administered/documented within regulatory requirements, and/or failed to ensure that (critical) blood glucose levels were addressed by a physician/nurse practitioner for two of four residents reviewed for change in condition. These failures resulted in R1 sustaining critical blood glucose levels ranging from 413-500 (without intervention) for a total of 8 days within 1 month. These failures also resulted in R2 sustaining a critical blood glucose level of 400 (without prescribed sliding scale insulin) for 11 hours.Findings include:On 8/21/25, IDPH (Illinois Department of Public Health) received neglect allegations due to facility staff refusing to contact 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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Actual harm · Gcited before2025-03-07 · 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 observation, interview, and record review the facility failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to a resident who is at high risk for skin impairment. The facility failed to formulate wound/pressure care plan and implement LAL (Low air loss) mattress manufacturer's recommendation in prevention and management of wound care. These failures resulted R54 to develop DTI (Deep tissue injury) on right heel. This deficiency affects all five residents (R28, R36, R45, R54 and R59) in the sample of 17 reviewed for Wound/Pressure ulcer prevention and treatment management. Findings include: On 3/4/25 at 8:07AM, Observed R28 sleeping in a LAL (low air loss) mattress bed with V10 Family member at bedside. V10 said that R28 is totally dependent with ADLs (Activity of Daily Living). V10 said that last week Friday (2/28/25), R28 re-opened her sacral pressure ulcer. V10 said she noticed it when she assisted 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 before2024-09-12 · 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 interviews and records reviewed the facility failed to treat one resident with respect and dignity by placing him in the hallway tied to a wheelchair and having pictures taken.This failure affected one of one resident (R5) reviewed for dignity. Using the reasonable person concept it is reasonable to conclude that R5 felt cold, uncomfortable, and dehumanized when he was sitting in a wheelchair, in the hallway, with a sheet, no shoes, no socks. The findings include: On 8/29/23 an image of identified resident R5 obtained. Image is of a male, with disheveled, long, black hair, and long facial hair. R5 sitting in a room, in a wheelchair, no socks or shoes, in a hospital issued gown, with a face mask on, below his chin. A second image of a male, dark skinned, sitting in a wheelchair, in the hallway, leaning forward, back exposed, no hospital gown is seen in the picture. R5 appears to be covering his face or head with a white sheet. Image matches with the identified hallway of the facility hallway, outside of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Actual harm · Gcited before2024-09-12 · 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 records reviewed the facility failed to follow their abuse policy to prevent unauthorized photos of a resident restrained to a wheel chair in the hallway. This affected one of three residents R5 reviewed for mental abuse. This failure resulted in R5 having unauthorized photos taken of him restrained to a wheelchair which is demeaning, and humiliating. Findings include: On 8/29/24 at 11:21AM V19, Certified Nursing Assistant (CNA), said on 7/26/24 I saw R5 had a gait belt around him. V19 said I was assigned to be R5's one to one, monitoring him. V19 said I talked to V11, LPN, and V5, DON, and the scheduler. V19 said I told V5 about the gait belt around R5 before she left like at 4:30PM. V19 said they said if you don't want to watch the patient, then go home. V19 said I left the floor and then I came back up to the floor around 6:00PM or 7:00PM and R5 had the sheet around him. V19 said I got fired because of this. V19 said I saw R5 with the sheet tied with two knots around his stomach and he…
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 · G2024-09-12 · tag F0604 — failed to not use physical restraints improperly — isolated
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 was not physically restrained by being tied into a wheelchair with a gait belt and a bed sheet. This failure affects one of three residents (R5) reviewed for restraint use. This failure resulted in R5 having his freedom of movement inhibited and ongoing agitation, aggression, and anxiety. It is reasonable to conclude that R5 felt embarrassed and dehumanized. The findings include: On 8/29/24 at 11:21AM V19, Certified Nursing Assistant (CNA), said on 7/26/24 R5 was on one to one monitoring, he was a lunatic. V19 said R5 was trying to throw himself on the floor. V19 said I saw R5 had a gait belt around him and I told them, I don't feel comfortable with the belt on him. V19 said I talked to V11, LPN, and V5, DON, and the scheduler. V19 said I told V5 about the gait belt around R5, before she left like at 4:30PM. V19 said I didn't say anything about the sheet. V19 said they said if you don't want to watch the patient, then go home.…
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 before2024-03-19 · 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 interview and record review, the facility failed to prevent an incident of physical abuse during a resident to resident verbal altercation for one resident (R4) of five reviewed for abuse in a total sample of 11. This failure resulted in R4 being physically attacked by R5 suffering from a bruised face and bleeding from the mouth after being hit in the face by R5. Findings Include: R4 is a [AGE] year old with the following diagnosis: schizoaffective disorder, psychosis, post traumatic stress disorder, and subdural hematoma. R5 is a [AGE] year old with the following diagnosis: Alzheimer's disease. A Nursing note dated 1/13/23 documents around 2 AM the nursing staff responded to a call from R4. Upon arrival to the room, R5 was observed assaulting R4. A general assessment on R4 was remarkable for left lower eye bruising/swelling and minimal buccal bleeding. On 3/1/24 at 12:26PM, R4 denied remembering getting into a fight with any other residents in the facility. R4 denied any having any problems with any…
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 before2024-03-19 · 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 interview and record review, the facility failed to perform dressing changes as ordered by the wound physician for one resident (R6) of three reviewed for wound care in a total sample of 11. This failure resulted in R6's wound(s) declining by increasing in size on two separate occasions. Findings Include: R6 is a [AGE] year old with the following diagnosis: paraplegia, osteomyelitis, pressure ulcer of the sacral region stage four, pressure ulcer of the right buttocks stage four, and pressure ulcer of the right hip stage 4. On 3/5/24 at 3:13PM, R6 stated, there is one full time wound nurse (V13) and one part time wound nurse (V12). R6 stated V13 left the country for over a month and the only time R6's dressings would be changed was when V12 was in the facility. R6 reported telling V2 (DON) the dressing changes weren't being changed and V2 reported having a conversation with the nurses about doing the dressing changes. R6 admitted the nurses continued to not change the dressing for about two weeks until…
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 before2023-12-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their practice to confirm and follow physician orders to monitor blood glucose and administer insulin per sliding scale as prescribed for a resident diagnosed with type 2 diabetes with hyperglycemia. This affected one of three (R8) residents reviewed for physician orders. This failure resulted in 13 missed opportunities for blood sugar checks and 13 opportunities for insulin administration, R8 was sent to hospital, evaluated and treated for diabetic ketoacidosis, R8's blood glucose 658mg/dl. Findings include: R8's face sheet shows diagnosis of type 2 diabetes mellitus with hyperglycemia. On 12/8/23 at 10:23 pm, V19 (R8 family) said when she visited R8 on 11/16/23 around 11:30am-11:45am, R8 was observed in the dining room slumped over in his wheelchair, V19 said she called out to R8 and R8 replied help me V19 said she informed the nurse of R8's condition. V19 said the Nurse checked R8's blood sugar and she informed her that it 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Actual harm · Gcited before2023-12-15 · 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 have an effective policy for contraband material to ensure that contraband is not brought into the facility. This affected two of two residents (R5 and R15), this failure resulted in R5 found unresponsive sent to hospital, tested positive for opioids on 9/6/23 and 10/31/23, R15 sent to hospital for chest pain and diagnosis with marijuana use. Findings include: 1. On 12/6/23 at 11:35 am, R5 observed alert to person, place, time and situation. R5 said on 9/6/23 he got heroin from someone in the facility, then R5 said he received heroin from someone that delivered the drugs to him. R5 said he was outside the front of the facility and someone in a car pulled up and dropped it off to him. R5 said he took too much heroin that day he overdosed. R5 would not say if he received deliveries of street drugs on any other day. V9 (Administrator) made aware of R5 alleged he got heroin from someone in the facility, then stating he got heroin from someone…
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 before2023-03-16 · 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 conduct daily skin assessment, follow physician's treatment orders and implement interventions in preventing the development and reopening of a pressure ulcer for two (R14 and R74) of four residents reviewed for pressure ulcers. This failure resulted in R14's healed pressure ulcer on the sacral area reopening and being classified as a facility acquired unstageable deep tissue injury and R74's intact skin developed a facility acquired Stage 3 pressure ulcer on the sacrum. Findings include: 1. R14 is an 89-year- old, female, originally admitted in the facility on 06/24/22 with diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. According to Wound Evaluation and Management Summary dated 03/14/23, R14 has a Stage 4 pressure ulcer on the sacrum. R14's current POS (Physician Order Sheet) dated 03/07/23 documented: Calcium Alginate - Apply to sacrum…
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 before2023-03-16 · 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 adequately assess residents for a fall risk, failed to have appropriate fall interventions in place, failed to ensure that staff are familiar with residents fall risk status and fall interventions and failed to provide appropriate and sufficient supervision for residents assessed as requiring staff assistance and supervision for Activities of Daily Living (ADLs). This failure affected two ( R15 and R62) of 14 residents reviewed for falls. This failure resulted in R62 falling in her room, being sent to the hospital where she was found to have a left hip fracture and required a surgical procedure; this failure also resulted in R15 falling, while walking outside, in the facility's smoking patio, without the use of assistive device, which resulted in a left foot fracture. Findings include: 1. R62 is a [AGE] year-old female who is a longtime resident with past medical history including, but not limited to acute respiratory failure with hypoxia, weakness,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Actual harm · G2023-03-16 · tag F0791 — failed to provide routine dental services — isolated
Provide or obtain dental services for 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 follow their policy and procedures for providing dental care for residents by not identifying dental care needs and not ensuring dental services were provided for residents. This failure applies to four (R19, R27, R36, R55) of four residents reviewed for dental care and resulted in (R55) being hospitalized due to a dental infection and facial cellulitis. Findings include: 1. R55 is a [AGE] year old male who originally admitted to the facility on [DATE] and still resides in the facility. R55 has multiple diagnoses including but not limited to the following: COPD, Type II DM, ESRD, moderate protein calorie malnutrition, HTN, anemia, dependence on renal dialysis, aphasia, abnormalities of gait and mobility. Facility progress note dated 3/7/23 states in part but not limited to the following: Upon rounds this morning, observed resident face swollen on both sides. Received orders to send to emergency room. Hospital records dated 3/8/23 state in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Potential for harm · D2026-05-29 · 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 observations, interviews, and record reviews, the facility failed to provide tracheostomy care in accordance with physician orders, including the administration of oxygen, and failed to date and label oxygen tubing in accordance with facility policy and procedure. This affected three of three residents (R65, R11, and R85) reviewed for oxygen therapy in a sample of 54 residents.Findings include:On 5/19/26 at 10:10 AM, two oxygen concentrators were observed by the nurses' station. The smaller oxygen concentrator was blue in color and could provide up to 5 liters of oxygen. The larger concentrator was grey in color and could provide up to 10 liters of oxygen.On 5/20/26 at 1:05 PM, V20 CNA (certified nurse aide) stated that R65 had an oxygen concentrator in her room, it was the smaller one. V20 stated that the concentrator did not go up to 10 L of oxygen. V20 stated that R65 was exhibiting shortness of breath at times.On 5/21/26 at 3:35 PM, V22 LPN (licensed practical nurse) stated that R65 was admitted to this facility with oxygen via a trach collar. V22 stated that she did…
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 before2026-05-15 · 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 residents who smoke follow facility smoking policy. This deficiency has the potential to affect all 44 residents on the 3rd floor reviewed for Resident Rights. Findings include:On 5/13/26 at 12:15PM, during observation surveyors smelled illicit substances on the 3rd floor hallways. On 5/13/26 at 12:15PM, V10 (Registered Nurse) confirmed with surveyor and identified illicit substance smell on the 3rd floor. V10 said that when they smell that on the floor, they call administration, but nothing gets done.On 5/13/26 at 12:20pm, V5 (Maintenance) said that there has been smell of illicit substances in the building, because the facility brings in new younger residents. V5 said administration is aware. On 5/13/26 at 12:30PM, V1(Director of Nursing) made aware of illicit substance smell on the 3rd floor, V1 verified that it did smell of illicit substances, said there has been concerns and have identified residents not following smoking policy, V1 said the facility has provided a twenty-one day letter of intent 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 · Dcited before2026-05-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure residents who were dependent on staff for showering and bed baths received those services for one of three residents (R2) reviewed for ADL assistance (Activity of Daily Living).Findings Include:On 5/13/2026 at 10:40am R2 was observed sitting on the side of his bed with a urine odor, soiled clothes and linen.On 5/13/2026 at 10:42am R2 said I have been asking the (Certified Nursing Assistant -CNA) could they please assist me with a bed bath and a change of clothes they say, yes and never return.On 5/13/2026 at 10:48am V4(Assistant Director of Nursing-ADON) said she will have R2 CNA come right away and assist him.On 5/14/2026 at 10:00am V17(Certified Nursing Assistant-CNA) said I was R2's CNA, I did return as soon as I finished with the resident I was with and assisted him with a bed bath, he did have a urine odor, and his clothes were soiled I work on all units; I was his CNA only once before I don't know how long it had been since he had a bed bath or shower. On 5/14/2026 at 11:00am V1(Director 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 · D2026-05-15 · tag F0755 — failed to provide safe pharmacy services — isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for one of three residents(R3) reviewed for medication administration.Findings include:On 5/14/2026 this writer reviewed an (Electronic Medication Administration Record-EMAR) for R3 that indicates on 4/23/2026 at 1700 Clonidine HCL 0.3mg by mouth for hypertension was not given the code (5) which indicates the drug was held and to see the nurses note, A medication Hydralazine HCL 50mg by mouth had a code of (5) and a medication Carvedilol 25mg by mouth with a with a code of (6) which indicates hospital and resident was in the facility.On 5/14/2026 at 1:30pm V18(Nurse) was asked did she administer R3's medication and V18 said those are my initial for 4/23/2026 at 1700, I did not administer R3's medications because he was sleeping I called his name three times, he was not in any distress, I did not return to try and administer again.On 5/14/2026 at 2:00pm V1 (Director of Nursing-DON) said the nurses should wake every resident up for medication administration. An…
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 · F2026-04-16 · tag F0803 — failed to meet residents' dietary needs — widespread
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 — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure that food substitutes offered to residents who declined the planned meal were of similar nutritive value to the original menu. This failure affected all 98 residents that consume food from the facility's kitchen. Findings include: Facility census, dated 4/13/26, documents 101 occupied residents at the facility. Record review of facility document titled, Diet Type Report, dated 4/14/26, list 3 residents that are NPO (nothing by mouth). On 4/13/26, facility presented document titled, (Facility) Substitution Menu Always Available, undated, that documents, in part, 1. Cheeseburger or Hamburger; 2. Hot Dog; 3. Deli Meat Sandwich; and 4. Peanut Butter and Jelly Sandwich which are the facility's substitutes if a resident does not prefer the meal being served. The substitution menu documents all sandwich type substitutions, with no vegetable or other balanced side. On 4/13/26 at 11:37am, R2 said, I have been here since March 6th (3/06/26). OH, and the food. The food is cold period there's no substitutes; all…
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 · Dcited before2026-04-16 · 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 cover the urinary catheter drainage bag for 1 (R2) resident. This failure affected one (R2) of three residents reviewed for urinary catheters.Findings include:On 4/13/26 at 11:37am, R2's urinary drainage bag was observed hanging uncovered from R2's wheelchair, with approximately 225 mL of clear yellow urine observed present in the bag. R2 said, They (facility staff) are not concerned about anything, you think they (facility staff) are concerned about my privacy bag? I had to call the ambulance myself when the balloon broke to my catheter. This place (facility) is not what you think it is. It's (facility) going downhill. Get them (facility staff) to get me my medications on time and more than just sandwiches and then get them (facility) to get me a privacy cover for my bag (urinary bag). Yeah, I would like a privacy cover.According to the Electronic Health Record (EHR) R2 has diagnoses including but not limited to type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure,…
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 · D2026-04-16 · tag F0605 — failed to not use drugs as a restraint — isolated
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 policy and procedure and failed to implement a valid PRN (as-needed) order for one resident (R2) receiving psychotropic medications, in accordance with federal regulations and facility policy. This failure affected one resident (R2) in a sample of three residents reviewed for medication administration. Findings include:According to the Electronic Health Record (EHR) R2 has diagnoses including but not limited to type 2 diabetes, hypertension, schizophrenia, atrial fibrillation, chronic right heart failure, and absence of left leg below knee.R2's BIMS (brief interview for mental status) score, dated 3/15/26, is 13 which indicates R2 is cognitively intact.On 4/13/26 at 11:37am, R2 said, I have been here since March 6th (3/06/26). I kept telling her (V14/Registered Nurse/RN) that they (facility nurses) had my medication doses wrong and giving them to me at the wrong time and they (facility nurses) wouldn't listen. They're (R2's medication orders) fixed now. Do you think I would have signed a consent (psychotropic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · D2026-04-16 · 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 ensure residents were free from significant medication errors and failed to follow their medication administration policies. These failures affected two residents (R2, R3) in a sample of three residents reviewed for medication administration. Findings include: R3's face sheet documents in part the following diagnoses: heart failure, hypertensive heart disease, type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, obesity. R3's minimum data set (3/5/2026) documents a brief interview of mental status (BIMS) summary score of 14, indicating that R3 is cognitively intact. R3's physician orders document in part active orders for the following medications: Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day for vitamin (1/10/2025), Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 40 mg by mouth one time a day for antihyperlipidemic (11/10/2025), Lantus Solution 100 UNIT/ML (Insulin…
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 · D2026-04-16 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to prepare/serve food in in manner that was palatable and attractive. This failure affected one resident (R3) reviewed for dietary services. Findings include: R3's face sheet documents in part the following diagnoses: heart failure, hypertensive heart disease, type 2 diabetes mellitus, end stage renal disease, dependence on renal dialysis, obesity. R3's minimum data set (3/5/2026) documents a brief interview of mental status (BIMS) summary score of 14, indicating that R3 is cognitively intact.R3's physician's orders (11/20/2025) document in part an active order for Regular texture, Thin consistency, for diabetic no pork and tomato productOn 4/13/2026 at 11:38 AM, R3 explained, The food here is terrible, let me show you what I mean. I had to take pictures because you wouldn't believe what they serve me. R3 showed surveyors pictures of food served to R3 including an unappetizing plate of plain white rice and mixed vegetables (50% of the plate was rice, the other 50% mixed vegetables, no protein), a roll of bread…
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 · Dcited before2026-03-18 · 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 follow physician order for STAT (Immediately) laboratory testing. This deficiency affected one (R8) of three residents reviewed for physician orders. Findings include:On 3/17/26 at 2:05PM, V13 (Registered Nurse) said that she received orders for STAT lab work to be drawn for R8, called lab and got a confirmation number. V13 said she does not know if they came or not because it was not on her shift anymore, she endorsed to upcoming shift for follow up pending lab work.On 3/17/26 at 2:31PM, V1 (Director of Nursing) said that her expectations for nurses are to carry out orders given from physicians or nurse practitioners and follow up, for STAT labs, should be called in and obtain a confirmation number and if endorsed to upcoming nurse for follow up, then nurses should call labs and check the estimated time of arrival or if the lab was not able to be drawn then notify the physician or nurse practitioner. V1 made aware that no labs were drawn for R8 on…
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 46 citations

Potential for harm · D2026-03-18 · tag F0790 — failed to provide dental care — isolated
Provide routine and 24-hour emergency dental care for 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 provide routine Dental services. This deficiency affected one (R7) of three residents reviewed for dental services. Findings include:On 3/10/26 at 1:45PM, R7 said that she chews on the left side of her mouth because on the right side of her mouth upper and lower teeth have holes and it is painful when food gets stuck.On 3/11/26 at 11:17AM, V1(Director of Nursing) stated that residents are to be screened upon admission and quarterly for any dental concerns and as needed. V1 said R7 has not been seen by dental services throughout her stay at the facility. R7 is a [AGE] year-old admitted to the facility on [DATE] with the following diagnosis in part but not limited to: Quadriplegia, unspecified severe protein calorie malnutrition, neuromuscular dysfunction of bladder, asthma, myasis, myopathy, essential hypertension.Facility Policy on Dental ServicesPolicy: It is the policy of the facility to provide medically related social services 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 · D2026-02-24 · tag F0627 — isolated
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and records review, the facility failed to follow its guideline on Discharge/Transfers for one of one resident (R5) reviewed for transfers in a sample of 11 residents.On 2/10/26 R5 was sent out for an appointment. V27 (RN) stated that R5 arrived at the appointment location with no face sheet, physician order, or medication administration sheet. During an interview on 2/18/26 at 10:40am, V2 (Director of Nursing) stated that staff are aware of resident's appointments the day prior to the appointment and should have the paperwork ready on the day of the appointment. V2 stated that the facility's protocol is for a face sheet and a physician order sheet to be given to the transporter when a resident is picked up. During an interview on 2/17/26 at 4:30pm, V20 (RN, R5's night nurse) stated that she was not aware that R5 had an appointment. V20 stated that she did not send R5 with paperwork to his appointment because she could not get access to the computer room to retrieve the face sheet and physician order sheet that she had printed.Facility policy titled Guidelines…
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 before2026-02-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to follow its guideline policy for activities of daily living for one of one resident (R5) reviewed for activities of daily living in a sample of 11 residents.On 2/10/26 R5 was sent out for an appointment. V27 (RN) stated that R5 arrived at the appointment location unclean, unkempt and has not been changed for some time. During an interview on 2/18/26 at 10:40am, V2 (Director of Nursing) stated that she was informed by R5's family that R5 was sent for his appointment on 2/10/26 unclean. V2 stated that R5's night nurse informed her that she did not have time to get R5 ready for his appointment. V2 stated that staff are aware of appointments the day prior to the appointment and should have the resident ready on the day of the appointment. V2 stated that R5 has a stage three pressure ulcer on his right heal which is being treated by the wound doctor. V2 stated that the facility's protocol is for a face sheet and a physician order sheet to be given to the transporter when a resident is picked up.During an interview on 2/17/26 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Potential for harm · D2026-02-24 · tag F0691 — failed to provide colostomy / ostomy care — isolated
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its colostomy care policy, resulting in a colostomy leak that led to potential skin irritation and infection. This applies to 2 of 2 residents (R3 and R8) reviewed for colostomy care in a sample of 11.The findings include:R3 is a [AGE] year-old male admitted on [DATE] with cognition intact as per 11/25/25 and admitted with an admitting diagnosis including colostomy and urinary tract infection (UTI).On 2/17/26 at 2:00 PM, R3 was observed in his bed with his colostomy bag leaking.On 2/17/26 at 2:10 PM, V5 (Certified Nursing Assistant / CNA) stated that she didn't get a chance to check on R3 upon his arrival back from the hospital. The colostomy shouldn't leak, and the nurses are supposed to take care of the colostomy.On 2/18/25 at 10:25 AM, R3 was observed in his bed with a new colostomy bag and was leaking through the base dressing. On 2/18/26 at 10:25 AM, V25 (CNA) stated that she will notify the nurse and that the colostomy…
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 before2026-02-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its indwelling catheter and colostomy care policy, as evidenced by colostomy leakage and failure to maintain the urinary catheter bag and tubing below bladder level. This applies to 2 of 2 residents (R3 and R8) who were reviewed for infection control practices in a sample of 11.The findings include:1.R3 is a [AGE] year-old male admitted on [DATE] with cognition intact as per 11/25/25 and admitted with an admitting diagnosis including colostomy and urinary tract infection (UTI).On 2/17/26 at 2:00 PM, R3 was observed in his isolation room (due to COVID-positive) with a contact isolation sign posted on the door. R3 was observed on his bed at an elevated position with a urinary catheter and bag in bed.On 2/17/26 at 2:00 PM, R3 stated, I just came back an hour ago from the hospital. My urine and stomach were hot, and my infection was too bad, and I came back from the hospital on Sunday (2/15), then I went back again on Monday (2/16) 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.
Infection Control Deficiencies · Deficient, Provider has date of correction
Potential for harm · D2026-02-18 · 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 interview and record review, the facility failed to ensure that staff follow its medication administration policy by failing to sign the medication administration record, failed to ensure that staff properly reassess and document effectiveness of pain medication, and failed to properly account for the receipt and disposition of a psychotropic medication. This failure affected one (R3) of four residents reviewed for nursing care.Findings include:R3 is a [AGE] year-old male admitted to the facility on [DATE] post open reduction and internal fixation (ORIF 1/16/2026). Face sheet documented the following past medical history: Fracture of unspecified parts of lumbosacral spine and pelvis, subsequent encounter for fracture with routine healing, person injured in unspecified motor vehicle accident, anemia, anxiety disorder, other psychoactive substance abuse, uncomplicated, etc.On 2/1/2026 11:00AM, R3 was observed in his room, awake and alert, said that facility is not controlling his pain and not getting his…
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 before2025-12-05 · 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 ensure the call light was within reach and working properly for R2 who was diagnosed with a tracheostomy and uses a communication board for 1 of 3 (R2) residents reviewed for accommodation of needs in a total sample size of twelve. Findings Include:R2 was diagnosed with Acute Respiratory Failure with Hypoxia, Tracheostomy and Hemiplegia affecting the left non-dominant side. Minimal data set section B (hearing, speech and vision) dated 10/6/25 documents: Persistent vegetative state/no discernible consciousness. No. Speech Clarity: No speech. Care plan dated 11/11/25 documents: R2 uses the following appliances: Communication board, card or writing pad/board. On 12/3/25 at 1:11PM, R2's call light string was observed hanging from the wall, on the floor, with the pull switch in a down position. R2 could not reach the call light. R2's call light did not illuminate above his room or make an audible sound. Surveyor checked the call light on the panel behind the nursing station. R2's call light did not display an…
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 before2025-12-05 · 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 interview and record review, the facility failed to follow their abuse policy by not ensuring R7 was free from verbal abuse by V18 (nurse). This failure resulted in V18 engaging in a loud verbal abusive argument resulting in R7 feeling threatened and belittled like a child. In addition, the facility neglected to ensure V18 provided care according to professional standard for R2 and R12 who had the diagnosis of Respiratory Failure with attention to Tracheostomy by not providing suctioning as needed. This neglect resulted in R2 having difficulty breathing. R12 having low oxygen saturation of eighty percent (88%). V18 also neglected to administer R6's nightly prescribed long-acting insulin as scheduled for 4 of 4 residents reviewed for abuse in a total sample size of 12. Findings include:On [DATE] at 11:44AM, R6 (R7's roommate) who was assessed to be alert and oriented to person, place and time said, V18 was yelling at R7. R6 said, V18 engaged in confrontational, loud, unprofessional argument with R6. On…
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 before2025-12-05 · 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 interview and record review, the facility failed to follow their treatment/services to prevent/heal pressure and non-pressure wounds policy for one resident (R3) with multiple pressure sores by not following physician recommendations/orders for wound treatments, failing to document treatments administered and failing to document weekly measurements/assessments of wounds for one of three residents reviewed for wound care. Findings include:R3's was admitted to the facility on [DATE] with a diagnosis of type II diabetes, protein malnutrition, dependance on ventilator, muscle wasting and anxiety.R3's plan of care dated 9/17/24 documents: R3 has an alteration in skin integrity and is at risk for additional and/or worsening of skin integrity issues related to: Impaired Cognition, Impaired Communication, Incontinence of bladder, Incontinence of bowel, Impaired Mobility Status, Impaired Nutritional Status, Diabetes, Comorbidities. Interventions include: Weekly measurements and documentation and Administer 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 before2025-12-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to supervise R9 who was identified as high risk for elopement and moderate risk for wandering during a smoking break. This failure resulted in R9 climbing on top of a gazebo, jumping a fence, leaving the facility unauthorized without a pass, sleeping in an abandoned home with no utilities and on a train station platform for six days in cold inclement weather for one of one reviewed for supervision. Findings Include:R9 was admitted on [DATE] with the diagnosis of acute respiratory failure, pneumonia, asthma, hypertension, anemia and sleep apnea. R9 brief interview for mental status score documents 14/15 which indicates cognitively intact.R9's wander risk assessment dated [DATE] documents a score of ten (10) which indicate a moderate risk for wandering. R9's wander risk assessment dated [DATE] documents a score of fifteen (15). Score eleven and above indicate high risk to wander.R9's elopement risk review dated 10/10/25 documents high risk 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
Potential for harm · Dcited before2025-10-31 · 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 up and follow through with obtaining a battery for a motorized wheelchair for a quadriplegic resident to ensure the resident can maintain his independence. This affected one of three (R1) residents reviewed for accommodation of needs.R1's face sheet shows diagnosis of diabetes, hypertension, chronic embolism, quadriplegia, history of traumatic brain injury, major depressive disorder, muscle wasting multiple sites, and fracture right leg. On 10/28/25 12:08pm R1 observed alert to person, place, and situation. R1 is observed resting in a Geri-chair in his room at the bedside. R1 said he can use his motorized wheelchair independently. R1 said the chair has been broke for a while. R1 said the aides have to take him around the facility. R1 said the aides take care of him. R1 said he would rather use his motorized wheelchair.10/29/25 at 12:43pm V3 (R1's power of attorney) said R1's wheelchair is broken, and it needs to be repaired. V3 said R1's wheelchair has been broken for months.10/29/25 at 1:14pm V2…
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 · D2025-09-08 · tag F0580 — failed to tell family and doctor about changes — isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, and failed to notify the physician and responsible party regarding critical blood glucose levels for two of four residents (R1, R2) reviewed for change in condition.Findings include:On 8/21/25, IDPH (Illinois Department of Public Health) received allegations that facility staff refused to contact a doctor when resident blood sugars were elevated.R1's diagnoses include type II diabetes mellitus. V3 (Family) is listed as the emergency contact on R1's face sheet.R1's (6/5/24) care plan interventions state report abnormal blood sugars to Medical Doctor. R1's (June 2024) MAR (Medication Administration Record) affirms blood glucose levels were (critical) high on the following dates: 6/1: 413. 6/7: 432. 6/15: 500. 6/18: 419. 6/20: 469. 6/23: 450. 6/24: 430. 6/27: 419. R1's (June 2024) Nurses Notes exclude (critical) high blood glucose levels and physician/responsible party notification of resident change in condition. On 9/4/25 at 2:20pm, surveyor inquired if…
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 · Ecited before2025-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
Provide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide nail care and foot care to dependent resident. This deficiency affected all four (R36, R45, R54, and R59) residents in the sample of 17 reviewed for Activity of Daily Living (ADL) Program. Findings include: On 3/4/25 at 8:19AM, Observed R59 in recliner chair with long dirty fingernails with V11 CNA (Certified Nursing Assistant). On 3/4/25 at 8:20AM, Observed R36 lying in bed with V11 CNA with dirty long fingernails. On 3/4/25 at 10:41AM, Observed R54 lying in LAL (Low air loss) mattress with V8 Restorative Nurse. He has tracheostomy connected to ventilator. He is totally dependent with ADLs care. Observed R54 has long dirty fingernails. Observed black matter underneath the fingernails. V8 said that CNAs (Certified Nurse Assistant) are responsible for providing nail care to resident during ADLs care. Observed R54's long thickened and discolored toenails. V8 said that CNAs should report to nurse when observed resident with long…
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 · Ecited before2025-03-07 · tag F0880 — failed to prevent and control infections — pattern
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 ensure appropriate infection control practices for residents on enhanced barrier precaution and during ADL (Activity of Daily Living) care. This deficiency affects all four (R28, R47, R49 and R59) reviewed for Infection Control Program. Findings include: R59 On 3/4/25 at 8:19 AM, After V11 CNA (Certified Nurse Assistant) transferred R59 from bed to recliner chair, she gathered all soiled linens with gloves on from the bed closer to her chest/upper body. The soiled linens touching her clothes and both arms. Then she placed the linen on top of the mattress. Informed V11 CNA of observation made. She said that she should gather the linen away from her and placed it in a plastic bag. On 3/4/25 at 9:58AM, Informed V2 DON (Director of Nursing) of above observation. V2 said that the CNA should gathered the soiled linen from the bed away from her body and placed it in a plastic bag. R28 On 3/4/25 at 10:11AM, Observed V16 CNA and V10 Family member…
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 before2025-03-07 · 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 protect and promote resident rights of a vulnerable resident. This deficiency affects one (R59) of three residents in the sample of 17 reviewed for Resident's right. Findings include: On 3/5/25 at 8:19AM, Observed R59 in recliner chair wearing sweater with multiple large food stained in front of her sweater. She is alert but confused and totally dependent with ADLs (Activity of daily Living). V11 CNA (Certified Nurse Assistant) said that her sweater is clean, but they cannot remove the food stained. V11 added that the facility does her laundry. On 3/4/25 at 11:14AM, Informed V6 Social Service Director of above observation. V6 said that they have to treat resident with dignity. R59 should be wearing clean and neat clothing. The CNA should change R59's sweater and dress her with clean and neat clothing. Facility's policy on Resident's right indicated: At a minimum, federal law specifies that nursing home must protect and promote the following rights of each resident. You have the right to: * Be treated with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Resident Rights Deficiencies · Deficient, Provider has date of correction
Potential for harm · Dcited before2025-03-07 · 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 resident call light is within reach. This deficiency affects 1 (R47) of 3 residents in the sample of 17 reviewed for Accommodation of needs. Findings include: On 03/04/25 at 07:57 AM, R47 observed in bed, call light behind bed on floor. R47 said he cannot find the call light, he looked for it but could not find it. On 03/04/25 at 08:08 AM, V14 (Certified Nurse Aide) said that call light should be within reach, said she is not sure why call light is not next to him. On 03/06/25 at 10:09 AM, V2 (Director of Nursing) said that all residents should have call light within reach to ask for assistance, call lights should not be behind bed or on floors. R47 is admitted on [DATE] with diagnosis in part but not limited to HTN, chronic respiratory failure with hypoxia, Pneumonia, PVD, Left lower extremity osteomyelitis status post left above knee amputation and right below knee amputation, Cerebrovascular disease. A focus care plan I require…
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 · D2025-03-07 · tag F0644 — isolated
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to submit for a PASRR level 11 (Preadmission screening resident review-PASRR) for 2 of 3 residents (R22 and R39) reviewed for PASRR level 11 in a sample of 17. Findings include: On 3/5/2025 at 11:30am R22 said I don't think I'm in a program for mental health. On 3/5/2025 at 12:30pm V 6(Social Services Director) said I was not aware that R22 had an order for psychological services or a change in her medication I will submit for a PASRR level 11 and make sure that if a program is prompted that it is the correct program. On 3/6/2025 at 10:00am V1 (Administrator) said the social services department is responsible for submitting for a PASRR level 11 the information would come from the psychotropic nurse, I'll make sure the social service department is aware of that information to assure that the resident's are in the correct program. An order summary report indicated that R22 had a gradual dose reduction for Risperdal 1 mg on 1/29/2025 order on 5/17/2024 for resident to receive psychological services as needed, psychiatrist consult…
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 before2025-03-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow side rail physician order and care plan. The facility also failed to implement safety transfer to a dependent resident who is high risk for fall affecting 2 of 3 (R37, R59) residents reviewed for Accident Hazards in a total sample of 17. Findings include: On 3/4/2025 at 9:15 AM, R37 in bed with three side rails up. R37 said she doesn't know why those rails were up and that she did not request it. On 3/4/2025 at 9:17 AM, V3 (Assistant Director of Nursing) stated R37 should have two side rails up but V3 said not sure of the policy. On 3/4/2025 at 11:11 AM, V8 (Restorative Nurse) stated there should only be two side rails up while in bed. V8 said one of the side rails was zipped tight today. On 3/5/2025 at 8:50 AM, V2 (Director of Nursing) stated side rail assessment is completed by Restorative at least quarterly for mobility, there should be a physician order, and no more than two side rails up. Review of R37 Medical Records read:…
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 · D2025-03-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview and record review the facility failed to ensure the gastrotomy tube placement was checked prior to administering medication for 1 of 1 resident (R49) reviewed for enteral feeding in a sample of 17. Findings include: On 3/4/2025 at 8:30am V12 (Licensed Practical Nurse-LPN) was observed by this writer administering medication and did not check for placement before administering, V12 was asked how the facility checks for feeding tube placement. On 3/4/2025 at 8:33am V12 said we check for gastric residual, I guess I forgot. On 3/4/2025 at 1:00pm V1 (Director of Nursing-DON) said the nurses should check for feeding tube placement by pulling up gastric residual and by listening to gastric sounds via stethoscope. A review of R49 admission Record indicates that R49 has a diagnosis of gastrostomy status, dysphagia. A care plan dated 3/12/2024 that indicates R49 has an intervention to assess/check for gastric residual volume per facility policy and procedeure. Facility Policy: The facility was unable to present a feeding tube placement policy.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Potential for harm · Dcited before2025-03-07 · tag F0812 — failed to store, cook, and serve food safely — isolated
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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident refrigerators have recorded temperature log affecting 2 of 3 (R28, R29) residents reviewed for resident refrigerator in a sample of 17. Findings include: On 03/04/25 at 08:03 AM, Observed R29 personal refrigerator with 8 soda cans, 2 juice bottles, 1 container of [NAME] slaw salad not dated, the temperature log last updated on 2/3/25. No March 2025 log available. On 03/04/25 at 08:03 AM, R29 said that the staff usually comes in everyday to check the refrigerator temp log, they have not been in here yet. On 03/04/25 at 12:04 PM, R29 said that staff has not come in yet, not sure why. On 03/05/25 at 12:04 PM, V5 said that housekeeping logs the temperature every day to monitor refrigerator for temperatures and food. On 03/06/25 at 10:52 AM, V1 (Administrator) said that housekeeping monitors resident personal refrigerators daily and records logs, V1 said they are unable to find personal refrigerator policy. Facility's Policy on…
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 · D2024-09-12 · 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 interviews and records reviewed the facility failed to follow their policy to report potential abuse violations to the abuse coordinator for one (R5) resident reported to be restrained, pictures were taken, and details of his care/condition were shared over the phone to unknown persons. This failure affected 1 of 3 residents reviewed. This failure resulted in perpetrator remaining with R5 to provide one on one care for the duration of his shift. The findings include: R5 is [AGE] years old with diagnosis including, but not limited to Convulsions, Alcohol Abuse with Alcohol Induced Anxiety Disorder, Depressive Episodes, Schizoaffective Disorder, Dementia, Acute Cystitis, and Bacterial Pneumonia. R5 was admitted to the facility on [DATE] around 2:00PM - 2:30PM (per DON). At 6:02PM R5 was ordered a psychiatric transfer, and transferred to the hospital on 7/27/24 at 12:25AM. R5 was admitted to the hospital. On 8/29/24 at 11:21AM V19, Certified Nursing Assistant (CNA), said on 7/26/24 I saw R5 had a gait belt…
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 before2024-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to de-escalate a verbal altercation that escalated to physical altercation, R6 hit R7 with a cane. This affected 2 of 2 residents (R6, R7) reviewed for supervision. Findings include: Facility final report to the department with date of incident of 8/19/24 denotes in-part, R6 and R7. Brief description of incident: above residents were out on patio for supervised smoke break. R6 asked R7 a question, when R6 didn't receive anticipated response, he swung his cane and hit R7. R7 became upset and picked up chair and hit R6. Nurse on duty was immediately called to area, residents were separated. Nurse performed assessment of both residents, with no new areas of concern noted. Physician (psychiatrist) for both residents was called with orders to send R6 to nearest emergency room and to monitor R7. 1:1 supervision provided to both residents pending discharge of R6. Facility room change will be initiated upon R6 return. Conclusion: abuse is the willful intent 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 · D2024-09-12 · 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
Based on interviews and records reviewed the facility failed to ensure a STAT order for a chest x-ray for new chest bruising was carried out within 4 hours. This affected one of one (R1) residents reviewed for radiology orders. The findings include: On 8/28/24 at 2:10PM, V2 Registered Nurse said, a STAT order means as soon as possible. On 8/28/24 at 1:59PM, V3 LPN said, on 7/29/24 when I came on shift, I was told we were waiting for an x-ray on R1. V3 said they said would get there. V3 said, then during my 5:00PM medication pass I was notified that R1 was not breathing. I assessed him, felt for a pulse, he was cold, not breathing, I called a code blue, and called 911. On 8/30/24 at 11:10AM, V5 DON said, on 7/29/24 R1 had yellowish and purplish bruising, right under the breast area. V5 said, we asked the nurse practitioner to assess him. V5 said, she ordered labs and x-rays. V5 said, we were waiting on diagnostic company to come in, then R1 had a change in condition, and he was sent out. V5 said, STAT means right away, the expectation is they are in the facility within 4 hours. V5…
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 · Ecited before2024-05-03 · tag F0812 — failed to store, cook, and serve food safely — pattern
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 discard potentially hazardous food (PHF) items by the use-by date. This failure has the potential to affect 15 residents who would receive the sandwiches from the kitchen. Findings include: On 04/30/2024 at 7:21AM, during observation with V25 (Dietary Aide), the cooler was observed with 15 prepared cold cut sandwiches placed in a pan with use by date of 4/24/2024. On 04/30/2024 at 7:21AM, during interview with V25, V25 stated that the 15 prepared cold cut sandwiches should have been discarded on 04/24/2024. On 05/01/2024 at 10:27AM, during interview with V28 (Food Service Director), V28 stated that the any prepared cold cut sandwiches should have been discarded on the date indicated on the label. Review of facility policy with section entitled Food Safety and Sanitation, policy on Dating and Labeling developed on 04/2017 indicated the following: Policy: The facility will follow safe handling and storage of PHF (potentially hazardous foods)/TCS (Time-Temperature Control for Safety) foods Procedure: - PHF/TCS…
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 · Dcited before2024-05-03 · 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 follow their policy to ensure that a resident dignity is maintained for one of three (R90) observed for dignity in a sample of 20. Finding includes: On 4/30/2024 at 11:35 AM, R90 was observed with V2 (Director of Nursing) from the hall way. R90 was lying in his bed. R90 has an indwelling catheter and the drainage bag was half filled with urine. R90 drainage bag was not put in the dignity bag. On 4/30/2024 at 11:45 AM, this writer observed with V6 (Licensed Practical Nurse) from the hall way R90 drainage bag with urine. V6 said that the drainage bag should have been in the dignity bag. On 4/30/2024 at 11:35 AM, V2 said that the drainage bag should have been in the dignity bag. R90 is a [AGE] year-old male admitted on [DATE] with a diagnosis not limited to quadriplegia, tracheostomy, depression, and flaccid neuropathic bladder. Facility Policy: DIGNITY As an extension of appropriate interactions between staff and residents, the following…
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 · D2024-05-03 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview and record review the facility failed to ensure clean resident room, bed, linens, and equipment are maintained. This deficiency affects one (R153) of three residents in the sample of 20 reviewed for providing Resident clean environment. Findings include: On 4/30/24 at 7:40AM, Observed R153 lying in bed with dirty bed sheet and pillows. The bed siderails, enteral feeding machine, IV pole and floor are dirty with stains of enteral feedings spillage. Called V8 Registered Nurse (RN) and showed observation. V8 said that house keeping is going to clean the room. On 4/30/24 at 9:43AM, V13 Housekeeping Aide (HA) said that he cleans the resident's room where R153 resides. Showed above observation made to V13 HA. V13 said that he already cleans the room, but he cannot remove the stains from the floor. V13 said that it has been like this since yesterday and he informed his supervisor. V13 said that the Certified Nurse Assistant (CNA) is responsible for cleaning the bed siderails and IV pole. On…
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 before2024-05-03 · 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 interview and record review the facility failed to ensure the resident is free from verbal and physical abuse from another resident. This deficiency affects one (R42) of three residents reviewed for resident-to-resident abuse in a sample of 20. Findings include: On 4/30/2024 at 8:00am, R42 said that on 4/1/2024 in the evening she was having a conversation with the nurse and walked out of the room yelling and slammed the door on her way out, R62 was walking past and started yelling and verbally abusing her, then pushed her to the floor calling her bad names. The nurse came out the room, helped R42 off the floor, R42 called the police stating that R62 was yelling at every one all day and nothing was done about it. R42 said that she is afraid of R62 and does not want him around her. R42 said that R62 returned to her room twice yelling and using profanity, and that she went to her friends room and sat with him, because I did not want to be in my room alone with him walking around the floors. On 5/2/2024 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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · D2024-05-03 · tag F0607 — failed to have anti-abuse policies — isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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 implement abuse prevention policy by failure to update Abuse assessment and formulate care plan after resident abuse incident occurred. This deficiency affects one (R81) of three residents in the sample of 20 reviewed for Abuse Prevention Program. Findings include: On 4/30/24 at 2:00PM, Observed R81 ambulatory, alert and oriented, and can verbalize needs to staff. R81 is admitted on [DATE] with diagnosis of Dementia, Opioid abuse, and weakness. Most recent Abuse/trauma screening done was on 4/28/23. No abuse care plan. R81's facility incident report dated 4/13/24 indicated: V6 Licensed Practical Nurse witnessed R81 and V21 Certified Nurse Assistant talking in the hallway. V21 CNA noted making inappropriate comment to R81. V6 LPN immediately separated the two and escorted V21 CNA out of the building. Social services will provide support follow up post incident. R81 was re-assessed and will continue to receive care in accordance with 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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Potential for harm · Dcited before2024-05-03 · 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 and record review, the facility failed to perform pacemaker check as ordered and obtain a copy of hospice plan of care for two of four residents (R63, R66) reviewed for quality of care in a sample of 20. Findings include: 1. On 04/30/2024 at 1:30PM, during record review, R63's electronic health records indicated presence of cardiac pacemaker and orders indicated pacemaker check every 3 months. There is no documentation of pacemaker check that can be located on R63's electronic health records. On 05/01/2024 at 1:19PM, during interview with V2 (Director of Nursing), V2 stated that she contacted the pacemaker company managing R63's pacemaker to ask for documentation of pacemaker check and she was informed that the last time R63's pacemaker was checked was in June of 2020. V2 stated that R63's pacemaker check should have been done every three months as ordered. Review of R63's face sheet indicated initial admission date of 11/18/2020. Review of R63's Order Summary Report dated 05/01/2024 indicated order for pacemaker check every 3 months with order date of 03/13/2023.…
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 before2024-05-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent worsening of acquired moisture associated skin disorder to resident who is at high risk for developing skin impairment. The facility also failed to follow up wound care physician recommendation. This deficiency affects one (R16) of three residents in the sample of 20 reviewed for Pressure ulcer prevention and treatment management. Findings include: On 4/30/24 at 7:35AM, Observed R16 lying in bed with oxygen via nasal cannula. She is alert and oriented, can verbalized needs to staff. She said that she has bed sore, and her buttock hurts. She said that sometimes it takes time for them to answer her call light when she needs to be changed. R16 is admitted on [DATE] with admitting diagnosis listed in part but not limited to Morbid obesity, Type 2 Diabetes Mellitus, Spinal stenosis, Muscle wasting and atrophy. Braden scale for predicting pressure sore risk dated 3/4/24 indicated at moderate risk. Active physician orders indicate: Apply…
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 · D2024-05-03 · 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 — 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 implement catheter care to resident with suprapubic catheter. This deficiency affects one (R153) of three residents reviewed for Catheter care management. Findings include: On 4/30/24 at 7:40AM, Observed R153 lying in bed. Observed brownish sediments attached inside the entire catheter tubing draining dark yellow orange urine. Called V8 Registered Nurse and showed observation made. V8 said that R153 has suprapubic catheter. V8 said that they monitor the catheter every shift for sediments and change catheter tubing/bag as needed. On 4/30/24 at 8:59AM, Informed V2 Director of Nursing (DON) of above observation. V2 said that they should monitor catheter every shift, catheter flush as needed and change catheter tubing and bag as needed. On 4/30/24 at 9:51AM, Observed V14 Wound Care Nurse (WCN) providing wound care to R153. Observed plastic wrapped around the urinary tubing approximately 10 inches from the catheter site. R153 said he did 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 · D2024-05-03 · tag F0756 — failed to review each resident's drug regimen — isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow up with pharmacy recommendation for physician response. This deficiency affects two (R16 and R63) of three residents in the sample for 20 reviewed for Pharmacy medication review. Findings include: 1. On 4/30/24 at 7:35AM, Observed R16 lying in bed with oxygen via nasal cannula. She is alert and oriented, can verbalized needs to staff. R16 is admitted on [DATE] with diagnosis listed in part but not limited to Major depression, Anxiety disorder, Opioid dependence. Active physician order sheet indicates Trazadone HCl oral tablet 50mg give 1 tablet by mouth at bedtime for prophylaxis; Atorvastatin calcium oral tablet 20mg give 1 tablet by mouth at bedtime for prophylaxis; Cyclobenzaprine HCl oral tablet 5mg give 1 tablet by mouth at bedtime for prophylaxis; Duloxetine HCl oral capsule delayed released particles 60mg give 1 capsule by mouth one time a day for prophylaxis; Latanoprost ophthalmic solution 0.005% instill 1 drop in both eyes…
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 before2024-05-03 · tag F0880 — failed to prevent and control infections — isolated
Provide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to clean and cover a nebulizer mask after each use. This deficiency affects one (R16) of three residents in the sample of 20 reviewed for Infection control protocol. Findings include: On 4/30/24 at 7:30AM, Observed R16 lying in bed with oxygen via nasal cannula at 2.5LPM. Observed nebulizer mask dirty and exposed, connected to machine placed on bedside table next to opened container of zinc oxide cream, 2 opened tubes of vit A and D ointments, empty pudding container and used spoon. R16 said that the nurse provides her nebulizer treatment when she has problem with breathing. On 4/30/24 at 8:43AM, Observed R16 lying in bed with oxygen via nasal cannula at 2.5LPM. She just finished eating breakfast. The dirty and uncovered nebulizer mask connected to machine still placed on bedside table, next to breakfast tray with the opened container of zinc oxide cream, 2 opened tubes of vit A and D ointments, empty pudding container and used spoon. Called…
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 before2023-12-15 · tag F0550 — failed to protect resident dignity and rights — pattern
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 interviews and records reviewed the facility failed to offer an alternative plan to promote resident rights for independent residents with community passes and the facility failed to follow their policy for Outside Community Pass Privileges before preventing the residents with independent passes from leaving the facility. This failure has affected 21 residents out of 21 (R10-R14, and R16- R31) reviewed for independent passes. The findings include: On 12/6/23 at 10:22AM V12, Activity Director, said she has been invited to Resident Council meetings. V12 said the only issue that has not been resolved is the changes to the outside passes. V12 said V8, Administrator, changed the policy and is under review. 1. R13 is [AGE] years old with diagnosis that include, but are not limited to Pulmonary Edema, Asthma, Diabetes, End Stage Renal Disease, Diabetes, and Obesity. R13's Cognitive assessment dated [DATE] notes a score of 14, intact. R13's Community Survival Skills assessment dated [DATE] documents R13 appears…
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 · E2023-12-15 · tag F0657 — failed to keep the care plan current — pattern
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to develop individual care plan interventions to reflect residents' community pass status and to reassess residents for community passes if issues arise that compromise the residents' safety for 21 residents (R10-R14 and R16-R31) out of 21 reviewed for independent passes. The findings include: On 12/6/23 at 10:22AM V12, Activity Director, said she has been invited to Resident Council meetings. V12 said the only issue that has not been resolved is the changes to the outside passes. V12 said V8, Administrator, changed the policy and is under review. 1. R13's Community Survival Skills assessment dated [DATE] documents R13 appears to be capable of unsupervised outside pass privileges. R13's Order Summary Report start date 11/17/23 may go out on LOA with meds (leave of absence). R13's care profile report instructions green pass. R13's care plan does not indicate the level of pass R13 has been assessed for. On 12/8/23 at 11:36 AM R13 said they are 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.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2023-03-16 · 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 — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a Registered Nurse was working at least 7 days a week, 8 hours a day. This failure has the potential to affect all 104 residents currently residing in the facility reviewed for nursing care. Findings include: On 3/13/23 at 3:15PM, V15 (Nursing Scheduler) was interviewed regarding nursing schedules. V15 said V2 (Director of Nursing), V3 (Assistant Director of Nursing), and V6 (Wound Care Director/Registered Nurse) all work Monday through Friday. V10 (Registered Nurse) does work every other weekend. On 3/14/23 at 12:00PM, V10 was interviewed regarding staffing. V10 said he is the only registered nurse that typically works the floor. Says he works every other weekend. Reviewed nursing schedule for 2/25/23-3/18/23. Noted dates 3/4/23 and 3/5/23 to not have any Registered Nurse scheduled or working. Noted 3/18/23 to not have any Registered Nurse scheduled. Per facility Employee List states in part but not limited to the following: V2 (Director of Nursing), V3 (Assistant Director of Nursing), and V6 (Wound 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.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
Potential for harm · Fcited before2023-03-16 · 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 observations, interviews, and record reviews, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not ensuring the kitchen environment and food preparation equipment was thoroughly cleaned, failed to ensure the food preparation area was free of personal equipment, and failed to wear hair restraints properly. This failure has the potential to affect all 105 residents currently in the facility. Findings include: On 03/14/23 from 08:46 AM - 11:20 AM Observed V36 (Cook) with her hair exposed from underneath hairnet on sides and back while meal prepping and cooking in the kitchen. Observed a large area of chipped paint on multiple ceiling vents above food prep sink, steam table, and clean dish rack. Observed rust stains and spatter on various ceiling areas in the kitchen. Observed multiple ceiling vents with heavy buildup of dust and dirt particles. Observed sides of stoves with heavy grease build up. Observed kitchen cart with heavy grease buildup. Observed serving spoons and food/storage bin with residue on them stored with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Potential for harm · F2023-03-16 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 policy and procedures for maintaining a clean environment by not ensuring resident's rooms are thoroughly cleaned, not ensuring resident's furnishings and medical care equipment are cleaned, maintained, and in good working condition, not ensuring residents clothing items are laundered as needed, and not ensuring shower rooms are thoroughly clean and in good repair. This failure applied to six residents (R10, R15, R19, R27, R36, R96) as well as the third floor shower room and has the potential to affect all 105 residents currently residing in the facility. Findings include: On 03/13/23 10:26 AM, Observed R10's bed with dirt build up on rails. On 03/13/23 at 10:55 AM, Observed R15's bed frame with dirt build up. R15 stated he would like his bed frame to be cleaned. On 03/14/23 at 11:52 AM, Observed R15's room area with several bags of clothes in various places. R15 stated he could use another cabinet to store his belongings. On…
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 · E2023-03-16 · tag F0761 — failed to label and store drugs safely — pattern
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
Based on observation, interviews, and record reviews, the facility failed to follow its policy related to medication storage and labeling. This deficiency affected three (R41, R66, and R82) of three residents reviewed for medications and has the potential to affect the 55 residents currently residing on the third floor in the facility. Findings include: Per facility matrix dated 03/15/23, current census on the third floor is 55 residents. On 03/13/23 at 10:14 AM, during inspection of medication rooms and medication carts, the following were observed: Second floor medication cart number 2: Three medicine cups with six pills in each cup were observed stored in the medication cart. One medicine cup was labeled with R66's last name. The other two medicine cups were not labeled. V12 (Licensed Practical Nurse, LPN) stated, This one is labeled for R66. This one is for R41. It was not given because he (R41) just came back from dialysis. This cup is for R82 who just came down to smoke. V12 was asked on when medications should be administered once prepared. V12 replied, When we prepare 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 · D2023-03-16 · tag F0554 — isolated
Allow residents to self-administer drugs if determined clinically appropriate.
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 its policy related to medication self-administration for one (R13) of one resident reviewed for medications. Findings include: R13 is a [AGE] year-old, female, originally admitted in the facility on 12/24/2021 with diagnoses of Spina Bifida, Unspecified; Hydrocephalus, Unspecified; Unspecified Asthma, Uncomplicated and Mild Intellectual Disabilities. Per MDS (Minimum Data Set) dated 01/23/23 under Section C, R13 has a BIMS (Brief Interview for Mental Status) score of 13 which means little to no impairment in cognition. On 03/13/23 at 10:30 AM during inspection of medication cart on the third floor in the facility, it was observed that R13's Ventolin inhaler is not in the cart. V5 (Licensed Practical Nurse, LPN) was asked regarding R13's inhaler. V5 replied, R13 has the inhaler in her room. Surveyor and V5 went to R13's room and found the inhaler placed in her (R13) backpack. The inhaler was still connected to its chamber. V5…
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 · D2023-03-16 · tag F0561 — failed to honor residents' choices — isolated
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide community pass privileges to one of one resident (R302) reviewed for residents rights. Findings include: R302 was admitted to the facility 2/20/2023 with diagnoses that include Paraplegia, Bipolar Disorder, Schizoaffective Disorder and Major Depressive Disorder. MDS dated [DATE] assessed R302 to have a BIMS 14 which indicates is cognitively intact. On 3/13/23 R302 stated, I haven't been out on pass, since I've been here. A few weeks ago, my uncle came to visit with me and take me out on pass and when he arrived I was denied . The Social Service person told me that I couldn't go because I was in the facility's wheelchair, not my own which I was unaware of. I was very furious, pissed and let the staff know about it. I keep trying to be calm but it infuriates me that I cannot go outside of this place. But they just said, it's policy. No one has followed up with me about getting my own wheelchair and I would like to know when I can go…
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 before2023-03-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedures for providing assistance with activities of daily living by not ensuring dependent residents receive care and services to maintain good hygiene and grooming. This failure applied to three of three residents (R19, R27, and R69) reviewed for improper nursing care. Findings include: 1. On 03/14/23 at 12:55 PM, V28 (Family Member) stated she was here about a week ago and R19 was not clean. V28 stated the facility reports that R19 declines showers. V28 stated she observed R19's clothes to be soaked with urine. On 03/14/23 at 4:31 PM, Observed R19 to appear unkempt. Observed R19's pants to be stained with a large area dried urine and stored with his clean clothes in a large pile in his closet. R19's Current care plan documents he has an Alteration in grooming and hygiene secondary to poor self-care motivation. This problem is manifested by [Refusing/Resisting bathing; Refusing/Resisting wearing clean clothes;…
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 before2023-03-16 · 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 follow their policy and procedures for resident safety by not reporting and not investigating reports of unsafe resident behavior of drinking to intoxication in the facility. This failure applied to one of one resident (R36) reviewed for quality of care. Findings include: On 03/14/23 at 2:06 PM, V32 (Anonymous Staff) reported R36 gets drunk with a Certified Nursing Assistant every night. V32 stated V30 (Anonymous Staff) witnessed this being reported to V2 (Director of Nursing). V32 stated R36 drinks a pint to a pint and a half at night with staff. On 03/14/23 at 4:21 PM, R36 stated he used to be a heavy drinker. R36 stated he wishes he had someone to drink alcohol with on the 11-7 shift and he'd be even happier. On 03/15/23 at 1:58 PM, V30 (Anonymous Staff) stated they were aware of R36 drinking alcohol with staff and that alcohol bottles were found in his room. V30 stated pictures of the alcohol bottles were provided to V15 (CNA Supervisor/Scheduler).…
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 before2023-03-16 · tag F0880 — failed to prevent and control infections — isolated
Provide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to adhere to infection control standards while administering injectable medications. This failure applied to one (R30) of six residents reviewed for infection control during medication administration observation. Findings include: On 03/13/23 at 5:07 PM, V21 LPN was observed administering evening medications to R30. V21 prepared 1mg/1ml heparin injection and did not perform hand hygiene before or after preparation. V21 then administered the heparin medication to R30's upper left abdominal quadrant without the use of gloves. V21 was asked if they usually give heparin injections without the use of gloves and he said, this is the only resident that I will be touching and giving medication to at this time so it is ok. V21 used hand sanitizer after administration. Facility policy titled Heparin Subcutaneous Injection Administration (No revision date) states in part; Procedure: 3. Proper hand washing before and after administration. 4. Apply gloves. 6. Draw up the medication as ordered.
Infection Control Deficiencies · Deficient, Provider has date of correction
No harm found · C2025-03-07 · tag F0732 — widespread
Post nurse staffing information every day.
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 policy on posting direct care daily staffing numbers. This failure has the potential to affect 69 residents receiving care in the facility. Findings include: On 03/06/2025 at 11:30am this surveyor along with V23 (Scheduler) did not observe the daily staffing posting anywhere upon entrance into the facility. V23 was made aware that the daily staffing posting was not observed by this surveyor since 3/4/2025. V23 said that the daily staffing posting should have been posted at a designated area by the front desk. On 03/06/2025 at 11:45 AM, V2 (Director of Nursing-DON) said that the daily staffing posting should have been posted. BIPA Staffing Posting Requirement Policy: It is the policy of the facility, in cooperation with Medicare/Medicaid Services, (CMS), to comply with the requirement of daily posting of nursing staff in the facility. Procedure: 1) SNFs and NFs must post daily, at the beginning of each shift, the facility specific shift schedule for the 24-hour period, the number and category 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.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
No harm found · B2024-05-03 · tag F0640 — pattern
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 transmit assessments within 14 days of completion for three of three residents (R11, R43, R75) reviewed for resident assessment in a sample of 20. Findings include: On 05/02/2024 at 12:10PM, during record review with V26 (Minimum Data Set [MDS]/Care Plan Coordinator), R75's annual assessment dated [DATE] and R43's annual assessment dated [DATE] were not submitted yet. During this review with V26, R11's quarterly assessment dated [DATE] and completed on 04/05/2024 was submitted on 04/30/2024. On 05/02/2024 at 12:18PM, during interview with V26, V26 stated that the facility just completes all the assessments but V27 (MDS Consultant) reviews it and signs off on it to complete then she is the one that submits it. On 05/02/2024 at 2:08PM, during interview with V27, V27 stated that R75's annual assessment dated [DATE] with completion date of 04/16/2024 should have been submitted on 04/30/2024. V27 also stated that R43's assessment dated [DATE] with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

$548,244 in federal fines across 7 penalties. 3 Medicare payment denials on record.

$28,592 — penalty dated 2026-05-15
$87,360 — penalty dated 2026-02-18
$118,720 — penalty dated 2025-09-08
$32,954 — penalty dated 2025-03-07
$93,965 — penalty dated 2024-09-12
$131,599 — penalty dated 2024-03-19
$55,054 — penalty dated 2023-12-15
Medicare payment denial — starting 2026-03-15 for 12 days
Medicare payment denial — starting 2025-10-05 for 80 days
Medicare payment denial — starting 2024-04-06 for 46 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 INFINITY HEALTHCARE CONSULTING — 69 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 →

Rating	This home	Chain avg
Overall	1 of 5	2.0	-1.0 vs chain
Health inspection	2 of 5	2.1	-0.1 vs chain
Staffing	1 of 5	1.5	-0.5 vs chain
Quality measures	4 of 5	3.7	+0.3 vs chain

The other 68 homes this chain runs (chain average 2.0★, per CMS)

Showing 40 of 68; lowest-rated first.

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 / manager	Type	Role	Share	Since
A&M HEALTHCARE INVESTMENTS LLC	Organization	5% OR GREATER DIRECT OWNERSHIP INTEREST	100%	since 01/07/2019
MEISELS, JOSEPH	Individual	5% OR GREATER INDIRECT OWNERSHIP INTEREST	NO PERCENTAGE PROVIDED	since 01/07/2019
GRAHAM, CALLIE	Individual	W-2 MANAGING EMPLOYEE	—	since 01/07/2019

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

Follow the money — this home’s finances

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

$10.1M

Net patient revenuemost recent cost report

-24.6%

Operating marginrevenue minus expenses

Who pays — share of resident-days

Medicaid 90%Medicare 2%Other / private 8%

About 90% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$327per resident / day

operating cost

$9,932per month

≈ monthly operating cost

$262per 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 145424. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-07, 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.

What to do next

Understand itWhat this inspection record meansDeficiencies, scope & severity, and the fines — read them like an inspector does.→Afford itCan your family afford this?Model the care years, taxes, and what’s left in My Plan. Free, private, no login.→DecideIs this the right level of care?A two-minute check: skilled nursing, assisted living, memory care, or help at home.→