River Bluff Nursing Home

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.

40.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 39.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 41 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 304 beds and averages 152.2 residents a day — about 50% occupied, or roughly 152 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 4.19 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.52 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 3.86 hrs/resident/day on weekends vs 4.32 on weekdays — 11% thinner on weekends. RN hours go from 0.90 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

38 citations, most serious first. The 16 most serious are shown; the remaining 22 are one tap away and print in full.

• Actual harm · Gcited before2026-06-24 · 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 assess and monitor a resident after a significant weight loss and failed to ensure a resident's nutritional supplements were implemented after a significant weight loss. This failure resulted in the residents having continued weight loss. This applies to 2 residents (R77, R67) reviewed for weight loss in a sample of 36. The findings include: 1. R77's Face Sheet printed on 6/24/26 showed R77 was initially admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's disease, and type 2 diabetes. R77's Weights summary showed R77's weights where: on 4/7/26 at 207.6 pounds (lbs.), on 4/21/26 at 200 lbs., on 4/28/26 at 200 lbs., on 5/1/26 at 189 lbs., on 5/16/26 at 189 lbs., on 5/26/26 at 188 lbs., on 6/17/26 157 lbs. R77's weight loss is calculated as being from 4/7/26 to 5/1/26 as an 8.7% weight loss in 24 days. From 5/26/26 to 6/17/26 as a 16.49 additional decrease in weight in 23 days. Both weight losses are…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-02-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to care for and transfer a resident in a safe manner to prevent a resident injury for 1 of 3 residents (R1) reviewed for resident safety and supervision in the sample of 3. This failure resulted in R1 falling while being cared for by facility staff. R1 was hospitalized due to the fall where he was diagnosed with an unstable vertebral (spine) fracture. The findings include:A facility incident report dated 2/3/26 showed, on 2/1/26, R1 fell backwards in his wheelchair, just after he was transferred into the chair, by facility staff. R1 began complaining of pain to his back on 2/1/26. R1 continued to complain of back pain on 2/2/6 and 2/3/26. On 2/3/26, R1 was emergently transferred to a local hospital, due to his worsening back pain, where he was diagnosed with a thoracic vertebral fracture. As of 2/5/26, R1 remained hospitalized due to his injury.R1's hospital CT scan (computed tomography scan) results dated 2/3/26 showed R1 sustained an acute fracture to his eighth thoracic vertebrae due to his fall on 2/1/26. The results…

  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 · G2026-02-05 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to effectively manage and treat a resident's pain after the resident fell in the facility. The facility failed to notify the attending physician/nurse practitioner of this resident's worsening pain. These failures apply to 1 of 3 residents (R1) reviewed for pain management in the sample of 3. These failures resulted in R1 experiencing worsening, severe lower back pain caused by a thoracic vertebral (spine) fracture he sustained when he fell in the facility. The findings include:A facility incident report dated 2/3/26 showed, on 2/1/26, R1 fell backwards onto the floor while seated in his wheelchair as he was being cared for by staff. R1 fell directly onto his back. R1 began complaining of pain to his lower back on 2/1/26. R1 continued to complain of back pain on 2/2/6 and 2/3/26. On 2/3/26, R1 was transferred to a local hospital, due to worsening back pain, where he was diagnosed with a thoracic vertebral (spine) fracture. R1's hospital CT scan (computed tomography scan) results dated 2/3/26 showed R1 sustained an 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
• Actual harm · Gcited before2024-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure fall prevention interventions were in place for a resident with a history of falls. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 falling and fracturing her left hip. The findings include: R1's Face Sheet (admission Record) showed an admission date of 12/13/23 with diagnoses to include dementia, depression, and left femur fracture (admitting diagnosis). R1's 3/19/24 Significant Change Assessment Minimum Data Set (MDS) showed severe cognitive impairment with a brief interview for mental status (BIMS) score of 6 out of 15. The MDS showed she was dependent upon staff for transfers from bed to chair transfers and she had not walked. The MDS showed she used a wheelchair for mobility and bed/chair alarms were used daily. R1's Progress Notes showed the following fall events: On 4/29/24 at 1:16 PM, .[R1] was laying towards her right side in front of her w/c (wheelchair) . On 4/26/24 at 4:42 PM, CNA (Certified Nursing Assistant) yelled out for help for fall resident…

  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 before2024-03-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify a pressure injury prior to becoming a deep tissue injury, failed to obtain treatment orders for a new pressure injury, and failed to implement pressure relieving interventions for a resident with multiple pressure injuries for 1 of 7 residents (R117) reviewed for pressure injury in the sample of 31. These failures resulted in R117 suffering a deep tissue injury to the right heel, a Stage 2 pressure injury to the right buttock, and a Stage 1 to the left lateral ankle. The findings include: R117's face sheet showed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of fracture of the right femur, weakness, polyneuropathy, heart failure, foot drop of the left and right feet, and chronic obstructive pulmonary disease. On 03/05/24 at 12:21 PM, R117 was in a wheelchair in his room. There were ace wraps to both legs and feet. R117 had black shoes on his feet and his feet were on the foot pedals. V15 Certified Nursing…

  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 before2024-03-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to identify decreased food intake for residents and implement interventions to prevent a significant weight loss for 2 of 6 residents (R50 & R87) reviewed for nutrition in the sample of 31. These failures resulted in a 5% weight loss in one month for R50 and R87. The findings include: 1. On 3/5/24 at 10:03 AM, R50 was in bed with the head of her bed raised. R50 had her tray table in front of her with her breakfast tray sitting on it. R50 had a sausage patty, hardboiled egg, roll, french toast, water, and chocolate milk. The french toast was cut in half and did not have any syrup on it. R50 picked up the hardboiled egg, looked at it and sat it back down on the tray table. R50 did not eat any of her breakfast. R50 was talking gibberish to herself and when asked questions. No staff were observed assisting R50 with breakfast. On 3/5/24 at 1:06 PM, R50 was sitting in her bed with the head of her bed elevated. R50 had her tray table in front of her with her lunch sitting on it. R50 had au gratin potatoes, broccoli,…

  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 · F2026-06-24 · 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 ensure clean kitchen pans and boiling water used for cooking were maintained in a manner to prevent contamination and failed to ensure frozen food items were labeled and dated. This applies to all 150 residents residing in the facility. The findings include:The facility's CMS form 671 dated 6/22/26 shows a census of 150 residents. On 6/22/26 at 9:10 AM, during the initial tour of the kitchen with V17 Dietary Supervisor, the freezer contained multiple plastic bags of chicken like products with no label of what they were or a date to show how old the product was. V17 when asked how do you know what is in the bags, V17 said the cooks know what it is. At 9:32 AM, V19 Dishwasher was working on the clean side of the dishwashing machine. V19 removed brown plastic bins from the clean side and stacked them on the wet floor mats next to the dishwasher. V19 then picked up the stacked bins and stacked them inside another clean plastic bin on the shelf under the clean side of the dishwasher. A brown plastic bin 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-24 · tag F0805 — failed to prepare food in a form residents can eat — pattern
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  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 pureed food was of a smooth consistency was served for 4 of 4 residents (R70, R77, R110, R125) reviewed for pureed food in the sample of 36. The findings include: On 6/22/26 at 10:00 AM, V18 Assistant Dietary Supervisor was pureeing the noon meal. V18 added pizza burgers, tomato sauce, thickener and water to the puree machine. V18 ran the machine for a few minutes and then poured the pureed contents into a serving pan. The puree did not visibly appear smooth. This surveyor tasted the puree and noted small bits of meat that had to be chewed. V18 did not taste the puree and covered the pan up and put into the warmer to be served for lunch. On 6/22/26 at 12:20 PM, R110 was seating in the dining room for the noon meal. R110 took one bite of pureed pizza burger and chewed for a while before swallowing. R110 did not take another bite of the pizza burger On 6/22/26 at 12:45 PM, the pureed pizza burger was tasted by two surveyors and found to be not smooth with bits of meat that needed to be chewed. At 12:56…

  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 · D2026-06-24 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a wider bed for a resident upon request. This applies to 1 of 36 residents (R78) reviewed for accommodation of needs in the sample of 36. The findings include: On 6/22/26 at 12:59 PM R78 stated that she had asked for a wider bed on admission, and no one has gotten her anything. (R78 was admitted to the facility on [DATE]). R78 stated that she fell out of bed at the hospital and now has a fear of falling out of bed. R78's Progress Notes dated 6/10/26 written by V28 (RN- Registered Nurse) state, Patient admitted yesterday afternoon from (Rehab Hospital), alert and oriented x 3. Anxious. States she is anxious because of her bed. The bed is not comfortable for her. Transferred to recliner which was also not comfortable and opted to return to bed. States she is afraid of rolling out of bed. Bed lowered all the way to floor. Patient states she has previously inadvertently rolled out of bed. Hand holds in place on either side of bed, which…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-06-24 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure PRN (when needed) psychotropic medications had stop dates. This applies to 3 of 6 residents (R12, R13 & R113) reviewed for unnecessary medications in the sample of 36. The findings include:1. R113's June MAR (medication administration record) shows, Quetiapine fumarate (anti-psychotic) oral tablet 50 MG (milligram), give 1 tablet by mouth every 24 hours as need for agitation PRN for agitation at HS (hour of sleep). Start date: 6/5/26. There is no stop date. She has received the medication 6 times since ordered. The pharmacist's recommendation to prescriber for R113 dated 6/16/26 shows, Findings/recommendation: this resident has new order(s) or was admitted /readmitted with order(s) for QUETIAPINE 50 milligrams QHS PRN. According to federal nursing facility regulations, PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. If this is the case, the prescriber should document 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 · D2026-06-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat a resident experiencing a change of condition in a timely manner. The facility also failed to ensure resident's ace wraps were applied to their legs as ordered. This applies to 3 of 36 residents (R2, R23, R95) reviewed for quality of care in the sample of 36. The findings include: R2's EMR (Electronic Medical Record) shows that R2 was admitted to the facility last on 4/27/26 with diagnoses including Respiratory Failure, Pneumonia and Hypertensive Heart Disease. R2's Progress Notes dated 6/19/26 at 8:15 PM written by V26 (LPN- Licensed Practical Nurse) state, Lethargy noted. Able to arouse for brief moments at a time. Skin warm and clammy. Upper trunk and facial diaphoresis noted. Afebrile. Increased audible congestion noted with occasional moist cough. Pulse ox 88-89% with O2 @ 2L/min. via N.C. HOB (Head of Bed) elevated for the ease of breathing. PRN (As needed) nebulizer with some effectiveness noted. B/P; 88/68. RN supervisor…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-24 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure appropriate assessment, treatment and care planning for a newly acquired pressure injury and failed to implement interventions to promote healing and prevent worsening of wounds for 2 of 7 residents (R7 and R82) reviewed for pressure in the sample of 36.The findings include: 1. R7's Face Sheet printed on 6/24/26 documented R7 was admitted to the facility and has diagnoses that include hemiplegia, cerebral infarction, gastronomy and colostomy status, aphasia and dysphagia. There is no documented diagnosis for pressure injury or wound. R7's Clinical Physician Orders reviewed on 6/22/26 includes orders to monitor wound of right outer ankle/float every shift for pressure ulcer (started 2/23/26) and to cleanse and dress right outer ankle every M-W-F (Monday, Wednesday, Friday/started 6/1/26). On 6/22/26 at 11:32 AM and 6/23/26 at 2:47PM, R7 was observed in bed with right ankle lying on bed, not floated or elevated. On 6/23/26 at 12:11 PM, V31 Licensed Practical Nurse provided wound care to R7's right ankle.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-24 · 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

  Based on observation, interview and record review, the facility failed to ensure a residents indwelling drainage bag was positioned below the level of the bladder to prevent the backflow of urine. This applies to 1 of 6 residents (R23) reviewed for catheters in the sample of 36. The findings include: R23's face sheet shows she has diagnoses including neuromuscular dysfunction of bladder, polyneuropathy, chronic kidney disease, personal history of urinary tract infections, and presence of urogenital implants. On 6/22/26 at 1:30 PM, R23 was sitting in her wheelchair. V13 and V34 (Certified Nursing Assistant-CNA's) transferred her from her wheelchair to her recliner chair using the mechanical stand lift. R23 requesting for her leg bag to be emptied. R23's leg bag was not positioned below the level of the bladder. The drainage bag was secured to the lower thigh, overlapping the kneecap and was not positioned downward. V13 emptied the urine into the urinal and did not secure the drainage cap. Urine was dripping down R23's leg. This surveyor asked V13 to check the cap. V13 said she closed…

  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 · D2026-06-24 · tag F0744 — failed to care for residents with dementia — isolated
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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 knew how to appropriately respond, assess and address behaviors for residents exhibiting behavioral symptoms with a diagnoses of dementia. This applies to 3 of 6 residents (R72, R75 & R113) reviewed for dementia care in the sample of 36.The findings include:1. R113's face sheet lists her diagnoses to include: dementia and agoraphobia with panic disorder. She was admitted to the facility on [DATE] from home. R113 resides on a locked memory care unit. On 6/22/26 at 12:22 PM, R113 was wandering around the unit independently with no assistive devices. She went out a door at the end of one of the hallways. The door goes to another enclosed area that goes through another door to the outside. The outside is an area enclosed with a fence and another exit door with an alarm. She was adamant about going outside. Several staff members responded to the door alarm and were trying to get her back inside. R113 refused to come back inside.…

  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 · D2026-06-24 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to administer medications as ordered. There were 40 opportunities with 2 errors resulting in a 5% error rate. This applies to 2 of 6 residents (R113 & R120) observed in the medication pass. The findings include: 1. On 6/22/26 at 12:32 PM, V3 Licensed Practical Nurse (LPN) was giving R113 a PRN (when needed) anti-psychotic medication. She stated, R113 had home medications they were using. She pulled out a bottle from a local pharmacy with R113's name on it. The medication was for Seroquel 25 mg (milligrams). V3 LPN stated, R113's orders were for 50 mg so she would give her 2 tablets. She put 2 tablets in a medication cup. It was observed there were 2 different pills in the bottle. V3 LPN said she hadn't noticed that before. 1 pill was the pill that should be in the bottle. The other pill she wasn't sure of. She pulled her phone out and googled what the tablet was. Google showed, it was a Seroquel tablet. V3 LPN, ok she would give the medication because google confirmed it was Seroquel. R113's June MAR shows,…

  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 before2026-06-24 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure medication was labeled with an open date, discarded once expired and failed to verify a resident's home medications prior to use. This applies to 3 of 6 residents (R10, R113 & R131) reviewed for medication storage in the sample of 36. The findings include:1. On [DATE] at 12:32 PM, V3 Licensed Practical Nurse (LPN) was giving R113 a PRN (when needed) anti-psychotic medication. She stated, R113 had home medications they were using. She pulled out a bottle from a local pharmacy with R113's name on it. The medication was for Seroquel 25 mg (milligram). It was observed there were 2 different pills in the bottle. V3 LPN said she hadn't noticed that before. R113's folic acid and metoprolol mediation bottles also had 2 different pills in the bottles. V3 LPN stated, she was told to use R113's home medications until they were gone. Those were the medications she was using. R113's June MAR showed, a physician order for Seroquel 50 mg PRN, folic…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$10,199 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $10,199 — penalty dated 2024-05-14
• Medicare payment denial — starting 2024-04-05 for 21 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.

Who owns this facility

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

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