Fairhaven Christian Ret Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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.

Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at 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.

Staffing

How full it usually is: this home is certified for 96 beds and averages 66.9 residents a day — about 70% occupied, or roughly 29 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 5.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.51 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 4.50 hrs/resident/day on weekends vs 5.39 on weekdays — 17% thinner on weekends. RN hours go from 0.79 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 95% is well above the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

21 citations, most serious first. The 16 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed toensure R1 was supervised while eating and food items were present within R1's reach. This failure resulted in R1 choking on R1's food and expiring. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/20/25 at 6:00 PM, when facility staff failed to ensure R1 was supervised at the dining room table when food was present. R1 impulsively grabbed food, put it in her mouth, choked, and died. The facility was notified of the Immediate Jeopardy on 3/26/25 at 9:28 AM. V1 (Administrator) was informed of the Immediate Jeopardy on 3/26/25 at 9:28 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 3/26/25; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The Face Sheet dated 3/22/25 for R1 showed diagnoses including Alzheimer'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-02-26 · 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 interview and record review, the facility failed to identify a significant weight loss for a resident (R4), failed to notify a resident's physician, dietician, and power of attorney for a significant weight loss and failed to obtain consistent meal intakes. These failures resulted in R4 experiencing a significant weight loss with no nutritional interventions for 22 days. This applies to 1 of 6 residents reviewed for nutrition in the sample of 28.The findings include:R4's electronic face sheet printed on 2/26/26 showed R1 has diagnoses including but not limited to chronic kidney disease stage 3, urinary tract infection, chronic obstructive pulmonary disease, and Alzheimer's disease.R4's facility assessment dated [DATE] showed R1 has no cognitive impairment and has not experienced weight loss.R4's care plan dated 10/24/25 showed, My health problems may impact my nutritional status .monitor and record food intakes, monitor/record weight. Notify physician and family of significant weight change.On 2/25/26…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-26 · 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 transferred and ambulated in a safe manner for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4 residents. This failure resulted in R1 falling and sustaining a right clavicle fracture. Findings include: R1's current Face Sheet provided by the facility on 2/26/25 shows R1's diagnoses include but are not limited to dementia, fracture of right clavicle, right shoulder pain, syncope and collapse, fatigue, pain in right knee, depression, and kyphosis. R1's current care plan last reviewed 2/8/25 shows R1 is at risk for falling due to her age, muscle weakness and overall physical decline. R1 requires contact guard assistance with bed/chair/toilet transfers and is ambulatory with a walker and staff assistance. Staff are to monitor R1 for unsteady gait and unsteady balance. R1's Minimum Data Set (MDS) dated [DATE] shows R1 requires supervision or touching assistance (helper provides verbal cues and/or…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-27 · 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 ensure a safe transfer was provided for 1 of 3 residents (R1) reviewed for risk for falls on the sample list of 3. This failure resulted in R1 sustaining a clavicle fracture during a stand lift transfer on 3/20/24. The findings include: The Nurse's Note dated 3/20/24 for R1 showed, called to room by CNAs (Certified Nursing Assistant) at 3:10 PM. CNAs stated R1 was transferring from toilet to wheelchair when she became weak and had to be lowered to floor by CNAs. R1 sitting on floor between toilet and wheelchair with her legs under her. R1 was holding onto the wheelchair and resting her head against door frame. Staff were able to lift R1 off floor, onto toilet, then transfer her into wheelchair, and lifted into bed. Had a bowel movement while in toilet. Vital signs: (temperature) 98.0, (heart rate) 100, (respiratory rate) 20, and (blood pressure) 158/90. Oxygen saturation 90% on room air. Range of motion x 4 extremities without pain.…

  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 before2023-08-29 · 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 have an ongoing assessment of a resident post fall, failed to ensure medical care and services were provided to a resident post fall in a timely manner for 1 of 3 residents (R2) reviewed for nursing care. This failure resulted a delay in care and pain control for a resident (R2) with multiple pelvic fractures tha required hospitalization and surgery. The findings include: R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include pain in right hip, generalized anxiety disorder, restlessness and agitation, chronic atrial fibrillation, weakness, essential hypertension, chronic congestive heart failure, and mild cognitive impairment of uncertain or unknown etiology. R2's facility assessment dated [DATE] showed she had moderate cognitive impairment and required assistance of one staff for most cares. R2's facility fall risk assessment completed 5/17/23 showed she is a high risk for falls. R2's care plan initiated 2/10/23…

  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 before2023-08-29 · 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 safely ambulate a resident with a history of falls. This failure resulted in R1 falling and sustaining a hip fracture and hematoma to the head. R1's hip fracture required surgical intervention and hospitalization. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: The facility's Incident Report dated 7/31/23 showed R1 fell in the lounge area and sustained a right hip fracture and hematoma to the right side of her head. This document showed she was a standby assist with a wheeled walker. The staff assisted R1 to the bathroom. R1 lost her balance and she fell on her right side. R1 said she felt dizzy before falling. R1 complained of right leg pain after the fall and her blood pressure was high (166/104). The resident was sent to the emergency room for further evaluation. R1 was admitted to the hospital for a right femur fracture. R1's Face Sheet dated 8/22/23 showed diagnoses to include, but not limited 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 · F2026-02-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to check the temperatures of food before serving and failed to use utensils to stir and remove food. These failures apply to all residents in the facility.The findings include:The CMS Center for Medicare and Medicaid Services form 671 dated 2/24/2026 shows there are 69 residents in the facility.1.On 2/24/2026 at 9:30 AM, V4 (Dietary Manager) said the food for the facility is prepared in the main kitchen and then placed in hot boxes and taken to the kitchenettes on the two nursing units on the second and third floor. V4 said the food temperatures will be taken on the units from the steam table prior to serving the food. At 11:10 AM, V5 (Cook) took the hot boxes containing the noon meal to the second-floor kitchenette. V5 placed all the food for lunch onto the steam table and then checked the temperatures of the regular meat and the pureed meat. V5 documented the temperatures on the log and then proceeded to get serving utensils. When V5 was asked about checking the temperatures of the rest of the food on the steam…

  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 · D2026-02-26 · 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 ensure an indwelling catheter was secured and failed to ensure catheter tubing was kept off the floor for 1 of 2 residents (R11) reviewed for indwelling catheters in the sample of 28. The findings include:On 2/24/26 at 11:49 AM, R11 was seated in his wheelchair in the dining room. R11's indwelling catheter drainage bag was under his wheelchair in a privacy bag. R11's catheter tubing was looped under the chair and touching the floor. R11 finished eating lunch at 12:39 PM and self-propelled his wheelchair from the dining room table to the nurses' station. R11's catheter tubing continued to drag on the floor. R11 self-propelled to V9 (Registered Nurse) at the nurses' station and obtained a chocolate wafer bar. R11 sat in the common area talking with another Certified Nursing Assistant (CNA) regarding his shower. R11 said he needed to use the bathroom first. V9 placed the foot pedals on R11's wheelchair and pushed him toward his room. R11'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-26 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure hot food was served at palatable temperatures for 3 of 3 residents (R3, R54, & R60) reviewed for dining in the sample of 28.The findings include:On 2/24/2026 at 9:49 AM, R3 was sitting in her recliner in her room. R3 stated she had some concerns about the hot food being served cold. R3 stated she eats in the dining room and by the time her food gets to her it is cold. R3 stated residents have brought it up at the Resident Council meetings.On 2/24/2026 at 12:14 PM, R3 was served her lunch meal of roast beef on a bun, au jus, fries, and cooked carrots. R3 stated her food was cold. R3 stated she is tired of food coming out cold. R54 was served her lunch and stated her fries and carrots were cold. At 12:57 PM, R60 stated her food was served cold.The Resident Council Meeting Minutes dated November 20, 2025, showed dietary concerns that included residents wanted more efficient ordering, so food is not cold. A resident suggested that staff…

  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 before2026-02-26 · 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 wear personal protective equipment (PPE) in a manner to prevent the spread of COVID-19. This applies to 1 of 2 (R19) residents reviewed for isolation precautions in the sample of 28.The findings include:R19's electronic face sheet printed on 2/25/26 showed R19 has diagnoses including but not limited to Alzheimer's disease, diarrhea, rash, and vascular dementia.R19's nursing progress notes dated 2/16/26 showed R19 tested positive for COVID-19 and was placed on contact, droplet, and airborne precautions.On 2/24/26 at 9:47AM, R19's door had a sign posted showing, Contact, droplet, airborne precautions.On 2/24/26 at 12:24PM, V13 (Certified Nursing Assistant-CNA) applied a gown, gloves, shoe covers, and an N95 mask over her surgical mask and entered R19's COVID positive room.On 2/25/26 at 8:53AM, V14 (CNA) came out of R19's room with a surgical mask underneath her N95 mask. V14 stated, I just wear a surgical mask under my N95 mask because I already had a surgical mask on so it doesn't make sense to take it off 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-01-08 · tag F0761 — failed to label and store drugs safely — widespread
  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, interview and record review the facility failed to ensure a multidose vial was labeled and dated when opened. This failure has the potential to affect all residents at the facility. The findings include: On 1/7/25 at 8:38 AM, this surveyor and V2 (Director of Nursing-DON) checked the 2nd floor medication room in the Healthcare Services Unit. A multidose vial of Tubersol (tuberculin (TB) testing solution) was noted in the refrigerator opened but not labeled with the date of opening. The preprinted date labeled on the vial was 9/16/24. V2 (DON) said this (vial) is months old, it should have been disposed of after 28-30 days. V2 said the Tubersol vial was used to all residents including new admits and any residents needing yearly TB testing including staff. V2 said any multidose vial should be dated and labeled once opened. The facility Policy titled Multi dose vial medication management dated 11/10/24 shows, 3. When a multi dose vial is opened, the nurse is required to complete sticker with the following- date of opening the vial, expiration date 28 days from…

  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 · Ecited before2025-01-08 · 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 staff used the required personal protective equipment (PPE) when entering COVID-19 isolation rooms and failed to ensure N95 masks were not worn over a surgical mask. The facility also failed to ensure gloves were changed to prevent cross contamination. This applies to 5 of 16 residents (R12, R10, R45, R54, and R27) reviewed for infection control in the sample of 16. The findings include: 1. R12's progress note dated 01/06/25 indicated R12 was on isolation for COVID-19. On 01/06/25 at 8:35 AM, there were signs on R12's room door indicating R12 was on airborne isolation, droplet isolation, and contact isolation. On 01/06/25 at 12:29 PM, V8 (Housekeeper) put PPE on to enter R12's room. V8 entered R12's room with gloves, gown, and a surgical mask on. V8 did not have on a N95 mask or eye protection. On 01/06/25 at 12:42 PM, V8 exited R12's room and stated she cleaned the room. V8 said she knows what PPE to wear when entering an isolation…

  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 · D2025-01-08 · 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 ensure ADL (Activities of Daily Living) assistance was provided for two of 16 residents (R54, R27) reviewed for ADL care in the sample of 16. The findings include: 1. R54's Face sheet shows she was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, delusional disorder, restlessness and agitation. R54's Care Plan dated June 12, 2023 shows R54 was frequently incontinent of bladder and bowel. I need staff assistance with incontinence cares and my hygiene needs. Observe me for verbal and non verbal cues that I need to use the toilet. R54's MDS (Minimum Data Set) dated December 2, 2024 shows R54 is not cognitively intact, R54 required partial/moderate assistance with toilet hygiene, and was dependent on staff for toilet transfers. R54 is occasionally incontinent of bowel and bladder. On January 6, 2025 at 8:47 AM, R54 was observed sitting in the television room in her wheel chair. R54 was observed 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-08 · 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 ensure a splint was placed for a resident with limited range of motion for 1 of 2 residents (R51) reviewed for range of motion in the sample of 16. The findings include: A facility assessment done on 11/18/24 showed R12 had limited range of motion to his upper extremity. On 01/06/25 at 08:51 AM, there was a sign above R51's bed. The sign indicated that a splint was to be placed on R51's right hand in the mornings. The initial wear time was 1-2 hours and progressing to wearing the split all day. The sign was dated 11/29/24. There was a blue splint sitting in the chair next to R51's bed. On 01/06/25 at 10:49 AM, R51 was in bed. There was no splint on R51's right hand. The splint remained sitting on the chair. R51's right hand was in a closed fist. R51 was asked if he could open his right hand. R51 could not open his right hand. On 01/06/25 at 1:12 PM and 2:27 PM, the splint remained off. On 01/07/25 at 9:10 AM, R51 was sitting in the common area in a chair. R51 did not have a splint on. On 01/07/25 at 9:10 AM,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-08 · 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 interview and record review, the facility failed to ensure a significant medication error did not occur for one of one resident (R28) reviewed for significant medication error in the sample of 16. The findings include: R28's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses of congestive heart failure, urinary tract infection, diabetes mellitus, generalized anxiety disorder, edema, atrial fibrillation, supraventricular tachycardia, cardiac pacemaker and hypotension. R28's Progress Note dated November 28, 2024 at 12:00 PM shows, Resident was given wrong medication by agency nurse this am. Writer informed DON (Director of Nursing) and on call nurse practitioner (NP) about this situation. NP ordered vitals every 30 minutes for two hours, then every hour for four hours. Give midodrine if blood pressure (BP) drops below 90. Resident started to exhibit symptoms of low BP. Writer checked BP and then administered midodrine as directed. Residents BP has since gone up to normal ranges.…

  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 · D2024-08-13 · 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 allow a resident (R1) choices regarding their care for 1 of 3 residents reviewed for resident rights in the sample of 10. Findings include: R1's electronic face sheet printed on 8/13/24 showed R1 has diagnoses including but not limited to Alzheimer's disease, low back pain, pain in left knee, and osteoarthritis. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment and requires staff assistance for activities of daily living. R1's care plan dated 1/6/23 showed, I have a diagnosis of Alzheimer's Disease. I am generally able to identify my needs but can be forgetful. I do not want to show my forgetfulness, so I may disguise this with humor or something clever .Provide me with options for my care and routine. I am very independent minded and appreciate choice and options. Talk with me in a quiet area, so that I can focus on you and re-approach if I am too tired. The facility's undated written statement from V5 (Certified…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$120,225 in federal fines across 1 penalty.

• $120,225 — penalty dated 2025-03-26

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

Who owns this facility

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

What families pay in IL