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Arcadia Care Rock Island

2545 24th Street, Rock Island, IL 61201 · For profit - Limited Liability company · 177 certified beds · (309) 788-0458 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Jul 2025Behavioral-health or dementia-care citation — no harm found (F0758)2 immediate-jeopardy citations$68,777 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $68,777 in federal fines (most recent 2025-07-22)
  • 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)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2525 24th St · (309) 788-7522 · Call to confirm hours
Pharmacy
Hy-Vee0.7 mi
2930 18th Ave · (309) 793-0684 · Call to confirm hours
Grocery
2427 20th Ave · (309) 788-2467 · Call to confirm hours
Park
1600 24th St · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.5%13.4%15.4%better
Long-stay residents who lose too much weight8.2%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.8%0.9%0.9%better
Long-stay residents with a urinary tract infection0.4%1.5%2.0%better
Long-stay residents with depressive symptoms76.8%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.2%3.1%3.3%worse
Long-stay residents whose ability to walk worsened4.0%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.7%18.3%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers1.1%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control24.5%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table7.8%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine85.7%63.1%79.4%typical
Short-stay residents rehospitalized after admission10.8%26.1%22.6%better
Short-stay residents with an outpatient ER visit29.2%13.9%12.0%worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

9.9%U.S. median 10.7%
Went back to hospital
not reportedno hours filed
Therapy hours / resident / day

Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot 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 SNF9.9%CMS range 6.7–15.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot 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 SNFs0.961.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.50
RN hours/ resident / day
0.65
LPN hours/ resident / day
2.90
Aide hours/ resident / day
4.05
Total nurse hours/ resident / day
0.29
RN hoursweekends
46.4%
Total nursing turnover
54.5%
RN turnover

How full it usually is: this home is certified for 177 beds and averages 66.0 residents a day — about 37% occupied, or roughly 111 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 4.05 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.90 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.41 hrs/resident/day on weekends vs 4.32 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.59 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

8
deficiencies at the latest standard inspection (2024-08-30)
5
at the previous standard inspection (2023-07-13)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · Kcited before2025-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    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 adequately supervise a known wandering resident (R1), failed to have systems in place to monitor the front door alarms after hours and failed to have interventions in place for a known faulty (electronic wandering device) door alarm system for one (R1) of twenty-two residents reviewed for elopement/wandering. These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of Vascular Dementia, eloping from the facility to a grassy area out front of the building, by a curb, close to a busy road attempting to get on a city bus. This failure has the potential to affect all seven (R4-R10) Elopement Risk residents who reside off the secured floor in the facility.These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 8/28/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · Jcited before2025-07-22 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement interventions to ensure a resident was free from physical abuse resulting in potential injury for 2 of 3 residents (R2, R11) reviewed for abuse in the sample of 12. The immediate jeopardy began on 6/11/25 at 6:50 PM when R1 returned to the facility from being evaluated at the acute care hospital after grabbing R11 by the neck. R1's care plan was updated to include 1:1 supervision on 6/11/25. No evidence was found of R1 being on 1:1 supervision until 6/18/25 after the second incident when R1 pushed R2 to the floor. V1 (Administrator) was notified of the Immediate Jeopardy on 7/18/25 at 11:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 6/18/25, prior to the start of the survey and was therefore Past Noncompliance or removed on 6/18/25 and the deficient practice corrected on 6/18/25, prior to the start of the survey and 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-07-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess respiratory status for one resident (R3) who displayed respiratory changes of three residents reviewed for change of condition in the sample of five.This deficient practice resulted in a delay in the assessment of the resident's respiratory status and subsequent need for additional medical intervention.The findings include:Physician Order Summary Report indicates R3 was admitted to the facility on [DATE] with diagnoses that include, Dysphagia, Cerebral infarction, Generalized Anxiety Disorder, Gastrostomy, Acute Respiratory Failure with Hypoxia.On [DATE] V7, LPN (Licensed Practical Nurse) stated that she was R3's assigned nurse on [DATE]. V7 stated that R3 was more anxious than usual, had a persistent dry non-productive cough and was obsessed with wiping his tongue with toilet paper. V7 stated R3 appeared to be trying to clear his throat or cough something up. V7 stated R3's mouth was dry, and she gave R3 mouth swabs. V7 stated she did not assess…

    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 · D2026-03-23 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform Cardiopulmonary Resuscitation (CPR) in a manner to provide adequate oxygenation to a resident (R2). This applies to 1 of 3 residents reviewed for change in condition in the sample of 18.The findings include:R2's electronic face sheet printed on [DATE] showed R2 had diagnoses including but not limited to hemiplegia and hemiparesis, cerebral infarction, type 2 diabetes, vascular dementia with behaviors, anxiety disorder, and dysphagia.R2's POLST (Physician's Orders for Life Sustaining Treatment) dated [DATE] showed, Full Code.R2's care plan dated [DATE] showed, Resident and/or responsible party has chosen to have resident a FULL CODE; CPR will be initiated if resident's heart and respirations stop.R2's nursing progress notes dated [DATE] showed, This nurse was notified by CNA (Certified Nursing Assistant) that resident was not breathing around 4:25AM. This nurse confirmed she was a full code and proceeded to residents' room, this nurse checked…

    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 before2025-10-28 · 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 implement interventions to assess a non-removable lower extremity cast for one of one residents (R1) reviewed for casts in a sample of three. Findings include: The facility's Cast Care policy, undated, documents to assess the cast every shift after the first 24 hours of application for the following: tightness or looseness (able to slip one finger between the cast and skin), circulation, motion, sensation, drainage, odor, and assess the skin for any signs of irritation. This form also documents to report and abnormal findings to the physician and document assessments regarding cast care in the nurses notes.R1's Treatment Administration Record, dated 9/19/25, documents to check CMST's (circulation, movement, sensation, and temperature) to right lower extremity for any abnormal findings and notify the MD (medical doctor) every shift. This order was discontinued on 10/7/25.R1's readmission orders, from the local hospital, dated 10/7/25, does not document…

    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 before2025-09-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was safely transferred with a full mechanical lift according to their plan of care for 1 of 3 residents reviewed for safety/supervision in the sample of 5.The findings include:R2's electronic face sheet printed on [DATE] showed R2 has diagnoses including but not limited to congestive heart failure, morbid obesity, muscle weakness, and muscle wasting.R2's facility assessment dated [DATE] showed R2 has no cognitive impairment and is dependent on staff for transfers.R2's care plan dated [DATE] showed, The resident has an ADL (Activities of Daily Living) self-care performance deficit related to weakness, balance/endurance deficit .the resident requires mechanical lift with 2 staff assist for transfers.On [DATE] at 10:40AM, R2 stated, The first I had an issue with (V3-Certified Nursing Assistant-CNA) taking care of me was about 2 months ago. The (full body mechanical lift) wasn't working right or the battery was dead or something and it…

    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 · F2025-08-28 · tag F0850 — failed to provide social-work services — widespread
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to employ a full time qualified Social Worker in a facility licensed for 177 beds. This has the potential to affect all 70 residents who reside in the facility.Findings include: The facility Director of Social Services job description, not dated, documents but not limited to, Qualifications: 1. Either a B.A. (Bachelor of Arts) in Psychology or Sociology; a B.A. or M.A. (Master of Arts) in Social Work; or a Licensed Clinical Social Worker's certificate. 2. Two years experience in the field of social work in a long term care environment is preferred.Facility Midnight Census Report, dated 8/22/25, documents occupied facility beds at 70 with empty beds at 107 and Detailed Census Report, dated 2/1/25 through 8/28/25, documents a daily census ranging from 66-81.On 8/28/25 at 9:35am, V2 (Administrator in Training/AIT) stated, We are licensed for 177 beds. V2 also verified that V15 (Social Service Director/SSD) is not Licensed and stated that she was a CNA (Certified Nursing Assistant).On 8/28/25 at 10:26am, V15 (Social Service…

    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 · D2025-08-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to treat a resident (R1) with dignity. This applies to 1 of 3 residents reviewed for dignity in the sample of 3. The findings include:R1's electronic face sheet printed on 8/2/25 showed R1 has diagnoses including but not limited to acute & chronic respiratory failure with hypoxia, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, dysphagia, and Raynaud's syndrome.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment, is dependent on staff for toileting, and is frequently incontinent of bowel and bladder.On 8/2/25 at 12:27PM, R1 was asked if he has ever had any issues with any staff members and he stated, Oh yes. When I first came back from the hospital I was transferring from the stretcher to the bed and it hit me really fast that I had to have a bowel movement so I asked the aide if she could take me and she said We aren't going to walk you in there today. You just got back from the hospital. You can…

    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 · D2025-08-02 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 keep a resident (R1) informed of the status of a grievance. This applies to 1 of 3 residents reviewed for grievances in the sample of 3.The findings include:R1's electronic face sheet printed on 8/2/25 showed R1 has diagnoses including but limited to acute & chronic respiratory failure with hypoxia, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, dysphagia, and Raynaud's syndrome.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment.On 8/2/25 at 2:02PM, R1 stated, I am very frustrated by a complaint I had with (V4-Certified Nursing Assistant (CNA). The staff are aware of it and they reported it for me. I hope it never happens again. (V4-CNA) hasn't taken care of me since that day but I didn't hear anything more about it. Nobody from Administration ever came and interviewed me or anything so I don't even know if they have the full story.On 8/2/25 at 3:16PM, V3 (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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-02 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement dietician recommendations for a resident (R1) receiving tube feedings. This applies to 1 of 1 residents reviewed for tube feedings in the sample of 3.The findings include:R1's electronic face sheet printed on 8/2/25 showed R1 has diagnoses including but not limited to acute & chronic respiratory failure with hypoxia, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, dysphagia, and Raynaud's syndrome.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and receives tube feedings.R1's care plan dated 3/17/25 showed, The resident requires tube feeding related to oropharyngeal dysphagia. Receiving tube feeding and water flushes for all nutrition & hydration needs According to RD (Registered Dietician): BMI (Body Mass Index)- 22.3 low for age. Has significant weight loss of 8.2% in 4 days (4/28-5/2); however, weights are relatively stable x 1m. Regimen meets/exceeds calorie &…

    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 · D2025-08-02 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physicians orders for a resident (R1) with a G-tube (Gastrostomy tube). This applies to 1 of 1 residents reviewed for G-tubes in the sample of 3.The findings include:R1's electronic face sheet printed on 8/2/25 showed R1 has diagnoses including but not limited to acute & chronic respiratory failure with hypoxia, hemiplegia and hemiparesis affecting left non-dominant side, cerebral infarction, dysphagia, and Raynaud's syndrome.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and requires tube feedings.R1's care plan dated 3/17/25 showed, The resident requires tube feeding related to oropharyngeal dysphagia. Receiving tube feeding and water flushes for all nutrition & hydration needs .provide local care to G-Tube (Gastrostomy Tube) site as ordered and monitor for signs and symptoms of infection.R1's physician's orders for 7/25/25-8/2/25 showed no orders for G-tube site care.On 8/2/25 at 3:09PM, V9 (Licensed…

    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 · D2024-08-30 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to provide the resident and the resident's representative the facility's written bed hold policy within 24 hours of transfer for two of two residents (R50 and R60) reviewed for bed holds in a total sample of 31. Findings include: The facilities Bed Hold Policy dated 3/2023 documents, Under Normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. Under certain conditions, we can reserve your existing bed for you, at your request, so when you return to the facility, you will have the same bed if you are hospitalized . If you are a private pay, Medicare, or Medicaid resident, we will hold your same bed and room for you as long as you wish, at a charge to you as established in the resident contract signed on admission. If your care is being paid for by the Veteran's Administration, we will hold your bed for 48 hours unless prior approval for a longer period has been received from the VA (Veteran's Administration) that initiated your contract.…

    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 · D2024-08-30 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review, the facility failed to develop a care plan to include a resting hand splint for one (65) of one resident reviewed for devices in a sample of 31. Findings include: R65's current orders for August 2024, documents LUE (left upper extremity) RHS (resting hand splint) wearing schedule: Patient should wear LUE RHS two hours prior to each meal and at night. Splint off during hygiene/bathing and feeding. If red or white spots are present, discontinue use and contact therapy. Before Meals and At Bedtime 07:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. On 8/27/24 at 11:20 AM and 8/29/24 at 10:40 AM, R65's hand splint was sitting on a shelf in her room. R65's current care plan does not have R65's resting hand splint documented. On 8/29/24 at 4:01 PM, V8 (Registered Nurse/Care Plan Coordinator) verified R65's care plan needed updated.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2024-08-30 · tag F0657 — failed to keep the care plan current — isolated
    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

    Based on observation, interview, and record review, the facility failed to revise a care plan to remove checking an AV/Arteriovenous fistula site; failed to include who to contact for emergencies/complications, failed to include a target weight; failed to have an assessment and care of the central dialysis port; and failed to include resident specific dialysis orders for two (R13 and R50) of 18 residents reviewed for care plan revisions in a sample of 31. Findings include: The facility's Comprehensive Care Plans policy dated 4/2017 documents, To develop a comprehensive, person-centered plan of care, consistent with the resident's rights, that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. The comprehensive care plan will include: services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, psychosocial well-being while preventing decline when possible, and areas of potential risk to the resident with interventions to eliminate or reduce risk. Care Plans are…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow physician's orders to flush an indwelling urinary catheter and failed to identify and document changes in urine output/characteristics for one resident (R76) of four residents reviewed for urinary catheters in the sample of 31. Findings include: Facility Policy/Change in a Resident's Condition or Status dated 3/2023 documents: The nurse will notify the resident's attending physician or physician extender when: There is need to alter the resident's treatment significantly; deems necessary or appropriate in the best interest of the resident. The nurse will record in the resident's medical record any changes in the resident's medical condition or status. R76's Physician Order Report indicates R76 was admitted to the facility on [DATE]. R76 is [AGE] years old and has diagnoses that include Diabetes Mellitus with Chronic Diabetic Kidney Disease, Stage 3 Chronic Kidney Disease, Personal History of Urinary Tract Infections, Polyneuropathy and Acute…

    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 · D2024-08-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to apply a resting hand splint for one (R65) of one resident reviewed for devices in a sample of 31. Findings include: Facility Splint-Brace Assistance, reviewed 6/24, documents When splints and other contracture devices are part of the plan, therapy will instruct nursing staff on their use and recommend a schedule for applying and removing the device. Facility Certified Nursing Assistant, updated 10/2013, documents Carry out assignments for resident care including restorative nursing procedures. R65's current orders for August 2024, documents LUE (left upper extremity) RHS (resting hand splint) wearing schedule: Patient should wear LUE RHS two hours prior to each meal and at night. Splint off during hygiene/bathing and feeding. If red or white spots are present, discontinue use and contact therapy. Before Meals and At Bedtime 07:30 AM, 11:30 AM, 04:30 PM, 08:00 PM. R51's Treatment Record for August 2024 has no documentation of R65's application of her resting hand splint. R51's medical record has no charting 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 · D2024-08-30 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 have specific dialysis orders related to the type of dialyzer, flow rate, and length of time; target weights; and care of the dialysis port for two (R13 and R50) of two residents reviewed for dialysis in a sample of 31. Findings include: Facility Care of Dialysis Resident policy, revised 5/17, documents To prevent complications pre and post dialysis treatment and to provide a safe environment. Monitor access site, identify any problems with site and report to physician and dialysis center. All physician orders are to be followed. 1. On 8/27/24 11:30 AM, R13 was in his room, alert and oriented, and had a right chest long central catheter port wrapped in gauze. At that same time R13 stated I go to dialysis five days a week here. R13's medical record documents the following diagnoses: End stage renal disease; Dependence on renal dialysis. R13's medical record has no specific dialysis orders related to the type of dialyzer, flow rate, and length of time; target weights; or care of the dialysis port. On 8/29/24 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 · D2024-08-30 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have pneumonia vaccination records documented in the resident record and failed to offer pneumonia vaccinations for two (R13 and R65) of five residents reviewed for pneumonia vaccinations in a sample of 31. Findings include: Facility Immunizations, revised 7/2022, documents It is the policy of this facility to offer Influenza and Pneumococcal vaccinations to all residents. Pneumococcal vaccine will be offered to all residents upon admission unless they report prior immunization. Facility will make best efforts to validate prior immunization. 1. R13's medical record documents V13 was admitted to the facility on [DATE], and has no documentation R13 has received, or was offered the pneumonia vaccine. On 8/27/24 after surveyor spoke to V4 (Infection Preventionist/IP), V4 IP documented a progress note in R13's medical record of the following: Resident offered PNA (pneumonia) vaccine and he reports that he will take. Informed resident that the clinic will be…

    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 · D2024-08-30 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have Covid-19 vaccination records documented in the resident record and failed to offer Covid-19 vaccinations for three (R13, R61 and R65) of five residents reviewed for Covid-19 vaccinations in a sample of 31. Findings include: Facility Covid Vaccine Policy, undated, documents The facility has made arrangements with a pharmacy to provide Covid vaccines to residents. The facility will continue to promote, encourage, and provide vaccination for all residents. 1. R13's medical record documents V13 was admitted to the facility on [DATE], and has no documentation R13 has received, or was offered the Covid-19 vaccine. On 8/27/24 after surveyor spoke to V4 (Infection Preventionist/IP), V4 documented a progress note in R13's medical record of the following: Resident offered Covid-19 vaccine and he reports that he will take. Informed resident that the clinic will be 10/15/24 and I will return with a consent for him to sign and he was agreeable. 2. R65's…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation and record review, the facility failed to ensure an allegation of verbal abuse was immediately reported to the Administrator for one of six residents (R4) reviewed for abuse in the sample of six. Findings include: The facility's Abuse Prevention Guidance Policy (revised 10/2022) documents the following: Employees are required to report any incident, allegation, or suspicion or potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence. The facility's Abuse Investigation (dated 06/06/24) documents the following: (V2 former Director of Nursing) reported to this administrator that when she gave (V12 Certified Nursing Assistant/CNA) a write-up for improper time clock usage/break…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-31 · 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 safely operate a mechanical lift transfer for one resident (R5) and failed to transfer one resident (R6) via mechanical lift as identified in the plan of care of three residents reviewed for mechanical lift transfers in the sample of seven. Findings include: Facility Policy/Mechanical Lift dated 2/2017 documents: A (full) mechanical lift should be used for heavy residents or for those who are disabled. Two staff members are required for this procedure. This policy's procedure for placing the sling under the resident does not include removing the sling once the resident is placed into a chair. Facility Policy/Mechanical Lifts dated 5/17 documents: Staff are not to operate the mechanical lift by themselves when a resident does not have independent sitting balance. Current Physician Orders indicate R5 was admitted to the facility on [DATE] with diagnoses that include Muscular Dystrophy, Diabetes Mellitus, Lymphedema and Obesity. Current…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-19 · 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

    Based on record review and interviews the facility failed to provide staff supervision to prevent a resident-to-resident altercation for two of three (R1) and (R2) residents reviewed for resident altercations in a sample of three. Findings Include: The facility abuse policy, named Facility Abuse Prevention Guidance, revised October 2022, documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. Purpose of this guidance is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment of residents. This will be done by-establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, identifying occurrences and patterns of potential mistreatment, immediately protecting and residents involved in identified reports of possible mistreatment and making the necessary changes 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-07-13 · 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 — the official record, unedited, may be distressing

    Based on observation, interview and record review, the facility failed to properly label and store daily medications. This failure has the potential to affect all 24 residents (R2, R8, R9, R16, R17, R21, R23, R26, R31, R33, R34, R36, R41, R42, R50, R52, R55, R59, R66, R71, R73, R178, R179 and R227 )residing on the facility Second Floor. FINDINGS INCLUDE: The facility policy (revised 05/01/2018) Storage of Medication directs staff, Medications and biological's are stored safely, securely and properly. (Pharmacy) dispenses medications in containers that meet regulatory requirements. Medications are kept in these containers. On 7/13/23 at 10:03 A.M. an observation of the facility's Second Hall Medication Cart showed twenty five various, unknown pills present, loose in the bottom of the medication cart drawer. At that time, V7/Registered Nurse stated, I'm not sure what those pills are or who they belong to.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to perform a PASARR Level I or II for one of three residents (R10) reviewed for PASARR (Preadmission Screening and Resident Review) screening in the sample of 32. Findings include: R10's Continuity of Care document, dated 7/12/23, documents that R10 was admitted to the facility on [DATE], and R10 has the diagnoses of Psychotic disorder, Bipolar disorder, Schizoaffective disorder, and Delusional disorder. R10's OBRA (Omnibus Budget Reconciliation Act) Screen, dated 6/27/17, documents that there is no reasonable basis for suspecting DD (Developmental Disorder) or MI (Mental Illness). R10's current medical record has no documentation of a PASARR level I or level II screen. On 07/12/23 at 11:57 AM, V1 (Administrator) confirmed that R10 should have had a PASARR Level I or II completed at admission, however it was not done.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to warrant the increase in an antipsychotic following a GDR (Gradual Dose Reduction for one of two (R38) residents reviewed for antipsychotics in the sample of 32. Findings include: The facility's Drug Reduction policy, dated 10/17, documents, Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Should the gradual dose reduction cause an adverse effect on the resident, and the gradual dose reduction is discontinued, documentation of this decision and the reasons for it must be included in the clinical record. On 07/10/23 at 10:14 AM, R38 was lying in bed with the television on. R13 (Certified Nursing Assistant) was in R38's room, applied a gait belt around R38, and assisted him to transfer from his bed into his wheelchair and positioned a bedside table in front of him. R38 was pleasant and did not display any behaviors. On 07/10/23 at 11:45 AM, R38 was sitting in a wheelchair with 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility to provide assistive devices during meals to ensure a resident maintains or improves their ability to eat or drink independently for one of one resident (R5) reviewed for assistive devices in the sample of 32. Findings include: The facility's Self-Help Devices (Adaptive Equipment) policy (undated) documents the following: Self-help feeding devices will be provided in the tray to clients who require them. R5's current face sheet documents R5's diagnosis to include: Alzheimer's disease with late onset; Type 2 diabetes mellitus with diabetic chronic kidney disease; Mood disorder; Anxiety disorder; Vascular dementia with agitation; Muscle weakness; Other lack of coordination; Cognitive communication deficit; Weakness; Adult failure to thrive; and Dysphagia, oral phase. R5's current Physician's Orders document the following order (initially ordered 03/23/23): Use of sippy cup and weighted utensils to aid with eating and drinking. On 07/10/23 at 02:00 PM, V14 (R5's daughter), stated, My mom's hands have always been a little…

    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 · D2023-07-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to cleanse the skin to be injected with alcohol and failed to wear gloves while administering an injection for two residents (R23 and R42) of five residents that were observed during medication pass, in a total sample of 32. Findings Include: The facility policy, Insulin Administration Procedure, dated (revised) 05/23 directs staff, To assure the proper administration of Insulin to residents. Wash hands and wear gloves. Clean the area of skin to be injected with alcohol. Allow the alcohol to evaporate completely before injecting insulin. Inject Insulin into the subcutaneous tissue at a 90- degree angle. Dispose of used syringe and needles in the Sharp's container. Remove gloves and wash hands. 1.) R23's current Physician Order Sheet dated July 2023 includes the following diagnosis: Type 2 Diabetes Mellitus. This same form includes the following medications: Humalog U-100 Insulin (Insulin Lispro) 100 unit/mL (milliliter) solution. Per Sliding Scale, subcutaneous, three times a day before meals. If Blood Sugar is…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-10 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication and failed to identify specific target behaviors for four residents (R9, R12, R32, R44) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 31. The facility also failed to provide a consent for antipsychotic medication administration for two residents (R12, R44) and failed to ensure an as needed psychotropic medication was limited to fourteen days for one resident (R42) of five residents reviewed for psychotropic medications in a total sample of 31. Findings include: Facility Policy/Psychotropic Medication dated 1/2021 documents: The facility will ensure that residents who have not used psychotropic drugs are not given them unless the medication is necessary to treat a specific condition that is diagnosed and documented in the clinical record. 1. The indication for any psychotropic medication will be documented in 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 · Dcited before2023-02-10 · 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 observation, interview and record review the facility failed to report a facial bruise of unknown origin to the State Agency for one resident (R44) of one resident reviewed for abuse in the sample of 31. Findings include: Facility Policy/Facility Abuse Prevention Guidance dated/revised 10/2022 documents: For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather facts to determine as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when all of the following conditions are met: - The source of the injury was not observed by any person; and - The source of the injury could not be explained by the resident; and - The injury is suspicious because of the extent of the injury or the location of the injury (for example: the injury is located in an area not usually vulnerable to trauma) or the number of injuries observed at one particular point in time or 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 · D2023-02-10 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately input hospice services in the MDS (minimum data set) assessment for one (R41) of 18 residents reviewed for MDS accuracy in the sample of 31. Findings include: The facility Resident MDS Assessment policy, dated 04/16, documents 3. Information derived from the comprehensive assessment enables the staff to plan care that allows the resident to reach his/her highest practicable level of functioning and includes, as a minimum: a. Medically defined condition and prior medical history (medical history before entering the facility and current medical diagnoses; f. Special treatments or procedures (treatments and procedures that are not part of basic services provided. On 2/8/23 at 2:05 pm, R41 was sitting in a wheel chair in the activity area/dining area with furrowed brow and refused to speak. The Physician Orders for R41, dated February 2023, documents a physician order for the local hospice service for R41 on 8/22/22. The current Care Plan for R41, documents hospice services were initiated on 4/7/22 and…

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

    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.

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

$68,777 in federal fines across 3 penalties. 1 Medicare payment denial on record.

  • $10,358 — penalty dated 2025-07-22
  • $14,069 — penalty dated 2025-07-22
  • $44,350 — penalty dated 2025-07-22
  • Medicare payment denial — starting 2025-08-15 for 20 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 ARCADIA CARE — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.3-0.3 vs chain
Health inspection 2 of 51.7+0.3 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 4 of 53.1+0.9 vs chain
The other 24 homes this chain runs (chain average 1.3★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
BARRISH GROUP LIMITED PARTNERSHIPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST9%since 08/26/2008
BARRISH, BRYANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST9%since 07/22/2008
GESUALDO, MARYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST9%since 01/01/2021
GESUALDO, RALPHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST9%since 07/22/2008
WINTER, THOMASIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER6%since 07/22/2008
BEHRENS, AMIEIndividualW-2 MANAGING EMPLOYEEsince 08/17/2021
BERGTHOLD, LOUISEIndividualCORPORATE OFFICERsince 10/01/2009
GENERATIONS HC NETWORKOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/22/2008

CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$7.5M
Net patient revenuemost recent cost report
-10.6%
Operating marginrevenue minus expenses
$896K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 22%Medicare 2%Other / private 76%

This home reported $896K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$304per resident / day
operating cost
$9,231per month
≈ monthly operating cost
$274per 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 145950. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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