Bella Terra Schaumburg
675 South Roselle Road, Schaumburg, IL 60193 · For profit - Limited Liability company · 214 certified beds · (847) 352-5500 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2024
- it has 3 actual-harm citations
- a high number of inspection citations overall (37) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $96,025 in federal fines (most recent 2024-11-04)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.1% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.4% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 98.7% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 1.2% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 1.6% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.8% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 15.2% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.6% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 22.7% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.8% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 37.4% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 26.5% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.5% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.22 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.33 | 2.22 | 1.80 | better |
‡ 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.
56.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 382 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.1% 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 90 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 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 51% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.5%CMS range 51.2–62.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 8.4–13.8 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 71.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 76.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 71.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.8% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 98.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.0%CMS range 3.9–8.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 214 beds and averages 160.2 residents a day — about 75% occupied, or roughly 54 beds typically open. It usually has some room. 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 3.65 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.51 hrs/resident/day on weekends vs 3.71 on weekdays — 6% thinner on weekends. RN hours go from 0.90 to 0.89 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
37 citations, most serious first. The 13 most serious are shown; the remaining 24 are one tap away and print in full.
- Actual harm · G2024-11-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 weigh, assess and monitor a resident with significant weight loss. This failure resulted in R137 losing 21 lbs. (pounds) in 14 days without being re-weighed or assessed. The facility also failed to provide physician ordered supplements for a resident (R118) with a history of significant weight loss. These failures apply to 2 of 7 residents (R137 & R118) reviewed for weight loss in the sample of 30. The findings include: 1. R137's face sheet lists her diagnoses to include: senile degeneration of brain, dementia, unspecified psychosis, major depressive disorder, cognitive communication deficit and hallucinations. R137's face sheet also shows she was admitted to the facility on [DATE]. She weighed 145.6 lbs. R137's initial admission dietary evaluation dated July 31, 2024 shows, [AGE] year old female admitted from the hospital with a dx (diagnosis) of psychosis. Past medical hx (history) includes dementia, depression, hyperlipidemia. Diet:…
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.
- Actual harm · Gcited before2024-11-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 resident was safely transferred for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a laceration of 11 centimeters (cm) requiring 13 sutures. The findings include: R1's face sheet printed on 11/4/24 showed she was [AGE] years old and diagnosed with dementia, malnutrition, and peripheral venous insufficiency. A facility assessment done on 8/29/24 showed R1 had severe cognitive impairments and was dependent on staff for transfers. R1's Care Plan printed on 11/4/24 showed R1 had a self-care deficit and impaired mobility. Listed under interventions showed R1 was dependent on two staff for transfers. The same care plan showed R1 had a cognitive deficit such as poor safety awareness, decreased comprehension, and impulsiveness. Listed under intervention was to modify environment as needed. On 11/4/24 at 9:05 AM, R1 was in bed. R1's left leg near her shin showed a dark line/scar about 8…
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.
- Actual harm · Gcited before2023-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 fall interventions were in place for a resident who is a HIGH risk for falls and failed to ensure a resident was safely transferred. This failure resulted in R135 falling on the floor in the dining room sustaining a right femoral neck fracture and requiring surgical intervention. This applies to 1 of 2 residents (R135, R459) reviewed for safety in the sample of 31. The findings include: 1. R135's face sheet shows he is a [AGE] year old male with diagnosis including fracture of the right femur neck, unspecified dementia without behavioral disturbance, unsteadiness on feet, cognitive communication deficit, weakness, monoplegia of upper limb following cerebral infarction affecting right dominant side, hydronephrosis, urine retention and aphasia. R135's Final Incident Report dated 9/19/23 documents on 9/13/23, (R135) stood up from chair in the dining room and lost his balance and fell hitting the right side of his body on the floor. 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.
- Potential for harm · Ecited before2026-01-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 resident's head of the bed was upright during meals (R9). This applies to 1 of 5 residents reviewed for safety in the sample of 47. The facility also failed to ensure a second-floor medication cart was locked when unsupervised. The findings include: 1. R9's face sheet printed on 1/15/26 showed diagnoses including but not limited to brain cancer, palliative care, heart disease, skin cancer, and protein-calorie malnutrition. R9's facility assessment dated [DATE] showed supervision needed for eating and on a mechanically altered diet. R9's dietary evaluation dated 12/26/25 showed dysphagia (difficulty swallowing) and dental problems of broken or fractured teeth. On 1/13/26 at 12:58 PM, R9 was lying in bed during the lunch meal service. R9 had a plate of mechanical soft food directly in front of him on the over the bed table. The meal consisted of diced carrots, pasta, and a roll. R9 had black, broken teeth in his upper mouth 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.
- Potential for harm · E2026-01-15 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 residents were offered bedtime snacks for 5 of 5 residents (R21, R83, R88, R100, and R118) reviewed for snacks in the sample of 47. The findings include:On 1/14/26 at 10:39 AM, During the group resident meeting all 5 residents present (R21, R83, R88, R100, and R118) stated they do not receive and are not offered bedtime snacks. R21's face sheet showed she was admitted to the facility 10/02/2019. R21's facility assessment dated [DATE] showed she has no cognitive impairment. On 1/14/26 at 10:29 AM, R21 said she is the Resident Council President. R21 said she can't even get an extra cookie or dinner dessert treat to take back to her room to eat later. R21 said she has asked staff if she could have something to take back to her room and they tell her no. R118's face sheet showed he was admitted to the facility 7/16/24. R118's facility assessment dated [DATE] showed he is cognitively intact. R118 said, That is a BIG NO. R83's face sheet showed she 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.
- Potential for harm · D2026-01-15 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 medical records were private for 1 of 1 resident (R105) reviewed for privacy in the sample of 47.The findings include:On 1/15/26 at 7:40 AM, upon arrival to the second floor, the medication cart was located down the hallway outside of a resident room. The cart had a computer mounted on top of the cart. The computer screen was open to R105's medications. There was no staff in the hall or near the cart. This writer waited by the cart for staff to arrive. V16 Licensed Practical Nurse (LPN) stepped out of a resident room, and said she was called away to a resident room, but the screen should have been closed.On 1/15/26 at 12:12 PM, V2 Director of Nursing said when a nurse steps away from her cart the computer should be closed and no resident information exposed. That would be a HIPAA (Health Insurance Portability and Accountability Act) violation.The facility's 12/8/25 policy for Notice of privacy practices states 1. The resident has a right to secure and confidential personal and medical records. Personal…
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.
- Potential for harm · Dcited before2026-01-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 staff thoroughly cleaned a resident who was dependent on staff for incontinent care for 1 of 1 resident (R159) reviewed for activities of daily living (ADLs) in the sample of 47.The findings include:R159's admission Record, provided by the facility on 1/15/26, showed she had diagnoses including, but not limited to, dementia, osteoarthritis, diverticulosis of small intestine, pressure ulcer of sacral region, acute kidney failure, urine retention, and altered mental status. R159's facility assessment dated [DATE], showed she has severe cognitive impairment and is dependent on staff for all cares. R159's skin impairment care plan initiated on 11/13/25, showed she remains at high risk for skin breakdown due to a history of multiple pressure injuries. The care plan showed one of the interventions in place was Keep skin clean and dry. R159's ADL care plan initiated on 11/20/25, showed she has an ADL self-care performance deficit and 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.
- Potential for harm · Dcited before2026-01-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to prevent, identify, initiate a treatment, and notify the physician of a new skin condition for 1 of 2 residents (R140) reviewed for non-pressure skin conditions in the sample of 47. The findings include:R140's face sheet showed she was admitted to the facility 3/27/23 with diagnoses to include senile degeneration of brain, hypokalemia, hypertensive heart and chronic kidney disease without heart failure, dementia without behavioral disturbance, generalized anxiety disorder, insomnia, and overactive bladder. R140's facility assessment showed dated 12/23/25 showed she had severe cognitive impairment and dependent upon staff for all cares. R140's current Physician Order Sheet showed no orders for treatment or monitoring in place of her bilateral shins.On 1/13/26 at 1:30 PM, R140 was in her room sitting up in her wheelchair. V26 (R140's son-in-law) was present in the room with R140. R140's shins were exposed. R140 had several dark bruises on each shin and steri-strips had been applied to an area on each shin.…
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.
- Potential for harm · Dcited before2026-01-15 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an insulin pen was disinfected prior to attaching the needle for 1 of 1 resident (R108) reviewed for insulin injections in the sample of 47.The findings include:R108's admission Record, provided by the facility on 1/15/2026, showed she had diagnoses including, but not limited to, dementia and type II diabetes mellitus. R108's Order Summary Report, printed 1/15/2026, showed the following active order for Humalog Kwik pen Subcutaneous Solution Pen Injector 100 units/ml. inject per sliding scale before meals and at bedtime. R108's facility assessment dated [DATE], showed she has severe cognitive impairment and requires substantial/maximal assist from staff, or is dependent on staff for all cares except eating. R108's careplan initiated on 11/7/2025, showed she is at risk for fluctuating blood sugars due to diabetes mellitus. The care plan showed the nurse should administer sliding scale per physician's order.On 01/14/2026 at 11:23 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.
- Potential for harm · Dcited before2026-01-15 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 provide incontinent care in a manner to prevent cross contamination (R45, R159) and failed to ensure staff wore the personal protective equipment (PPE) required when accessing a resident's intravenous line (R2) for 3 of 3 residents (R45, R159, R2) reviewed for infection control in the sample of 47.The findings include:1. R45's admission Record, provided by the facility on 1/15/2026, showed she has diagnoses including, but not limited to, early onset Alzheimer's disease, acute kidney failure, urine retention, major depressive disorder, and anxiety disorder. R45's facility assessment dated [DATE], showed she has moderate cognitive impairment. The assessment showed R45 is always incontinent of bowel and bladder and is dependent on staff for toileting hygiene and personal hygiene. R45's care plan initiated on 3/3/2024 showed she is dependent on staff for toilet hygiene. R45's care plan initiated on 5/18/2024 showed she was at risk for skin…
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.
- Potential for harm · E2024-11-20 · tag F0847 — patternInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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 and/or resident representative understood the arbitration agreement, and failed to educate staff providing the arbitration agreement to residents which applies to 4 of 4 (R20, R73, R144, R251) reviewed for the arbitration agreement in a sample of 30. The findings include: 1. R251's medical record showed R251 was admitted to the facility on [DATE]. R251's Health Care Arbitration Agreement (HCAA) was signed on 11/17/24 by R251. R251's medical record show R251 was assessed as being cognitively intact. On 11/20/24 at 10:00 AM, R251 stated she was in the facility a few days when a young man (V27 Guest Services Director) came into her room to have her sign some documents. R251 stated she knew one of the documents was an admissions packet. The other one had smaller writing. V27 did not explain what the other document was clearly. R251 stated they signed the papers, V27 stated if R251 had any questions to contact them. R251 stated it was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents (R115 and R13) were free of resident-to-resident verbal and physical abuse. This affects 2 of 30 residents reviewed for abuse in the sample of 30. The findings include: On 11/19/24 at 3:29 PM, R115 said R13 was cursing at him. R13 rolled over in his wheelchair and grabbed R115's left wrist area and had a good grip on it. R115 said R13 dug his nails in and did break the skin, but he did not bleed. R115 said he had an Xray, but nothing was broken. R115 said he and R13 did not get along well. On 11/19/24 at 2:35 PM, V1, Administrator, said he received a call from the nurse one evening saying R115 and R13 were yelling at each other and R13 was holding R115's wrist. V1 said R115 did have an Xray following the incident on 10/1/24. On 11/19/24 at 12:30 PM, V24, Licensed Practical Nurse (LPN), said a CNA (certified nursing assistant) told her he heard some yelling and asked her to address it. V24 said she went into R115 and R13's room and saw R13 by R115's bed. R13 had a hold of R115's wrist and they were yelling…
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.
- Potential for harm · D2024-11-20 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to notify the resident or their representative in writing of transfer. This applies to 2 of 30 (R31, R13) reviewed for notice of transfer or discharge in the sample of 30. The findings include: 1. R31's Progress Notes dated 10/20/24 at 5:15 PM show R31 is awaiting transport to the ER (Emergency Room). R31's Progress Notes dated 10/20/24 at 7:00 PM show an ambulance has arrived to transport R31 to the ER. R31's Progress Notes dated 10/20/24 at 9:38 PM show R31's POA (Power of Attorney) was called and informed that R31 was being admitted to the hospital. The facility was unable to provide documentation of a written notice regarding R31's transfer to the hospital. 2. R13's Progress Notes dated 10/30/24 at 3:26 PM show R13 was admitted to the hospital. The facility was unable to provide documentation of a written notice regarding R31's transfer to the hospital. On 11/18/2024 at 12:28PM, V19 (Registered Nurse/RN) said we give documents to the paramedics but not the family. On 11/19/2024 at 10:22AM, V23 (Licensed Practical…
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.
Show the remaining 24 citations
- Potential for harm · D2024-11-20 · tag F0625 — isolatedNotify 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 interview and record review the facility failed to notify the resident or their representative of the bed hold policy. This applies to 3 of 30 (R23, R31, R13) reviewed for notice of bed hold in the sample of 30. The findings include: 1. On 11/18/2024 at 3:39PM, V22 (Registered Nurse/RN) said he was caring for R23 when she went to the hospital in February of this year. V22 said he gave the paperwork to the EMTs (Emergency Medical Technicians) because the resident was confused that day. V22 said he does not recall if he notified the family of the bed hold policy. V22 said the bed is held for 10 days after a resident transfers to the hospital. V22 said he couldn't find anything in his documentation that shows he notified the family of the bed hold policy. 2. R31's Progress Notes dated 10/20/24 at 5:15 PM show R31 is awaiting transport to the ER (Emergency Room). R31's Progress Notes dated 10/20/24 at 7:00 PM show an ambulance has arrived to transport R31 to the ER. R31's Progress Notes dated 10/20/24 at 9:38 PM show R31's POA (Power of Attorney) was called and informed that…
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.
- Potential for harm · D2024-11-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was assessed prior to being diagnosed with a serious mental illness according to professional standards of practice. This applies to 1 of 1 residents (R99) reviewed for professional standards of practice in the sample of 30. The findings include: R99's face sheet shows, she was admitted to the facility on [DATE]. The same face sheet lists Schizophrenia as a diagnosis as of May 2, 2023 (2 years after admission). On November 20, 2024 at 10:38 AM, V25 Psychotropic nurse stated, she didn't know how R99 got that diagnosis. She has only been doing the psychotropics since May of this year. R99's progress notes dated May 2, 2023 documented by V30 R99's primary care physician (PCP) shows, .schizophrenia, continue seroquel to 25 mg (milligram) daily . The progress note does not show, any information to add diagnosis of schizophrenia. On November 20, 2024 at 2:19 PM, V30 R99's PCP stated, her understanding was that R99 came to the facility with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide ADL's (activities of daily living) for residents who require extensive assistance. This applies to 3 of 30 residents (R59, R118 & R49) reviewed for ADL's in the sample of 30. The findings include: 1. On November 17, 2024 at 1:15 PM, V6 R59's family complained, her dad doesn't get the care he needs. They don't change his clothes or his adult diaper in a timely manner. On November 18, 2024 at 10:40 AM, V8 Hospice CNA (Certified Nursing Assistant) was giving R59 a bed bath. She stated, R59 had the same clothes on from the last time she was here. She was last there on Thursday (November 14, 2024 - 4 days prior). R59's adult diaper was saturated with urine. V8 stated, he is always like this when she comes in to care for him. R59's care plan initiated on January 11, 2022 shows, Focus: R59 has an ADL self care performance deficit and impaired mobility AEB (as evidence by): impairments in over-all strength, generalized weakness, decrease activity tolerance, poor endurance secondary to Chronic complex medical…
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.
- Potential for harm · Dcited before2024-11-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure a residents skin preventive treatment was in place per physician orders. This applies to 1 of 5 residents (R59) reviewed for non-pressure skin conditions in the sample of 30. The findings include: On November 18, 2024 at 10:40 AM, V8 Hospice CNA (Certified Nursing Assistant) was giving R59 a bed bath. R59's adult diaper was saturated with urine. His coccyx was red with a small superficial open area. V8 stated, there usually is a dressing on his coccyx but it wasn't there today. On November 19, 2024 at 2:25 PM, V12 and V13 both wound care nurses stated, R59 did not have any open pressure injuries on his coccyx. It was more like MASD (moisture associated skin damage) now. R59 does have a treatment order in place as a preventive measure every shift. R59 has really declined and is on hospice now. He doesn't even get out of bed. The preventive treatment orders are to prevent any skin breakdown or pressure injuries from developing. R59's November 2024 treatment administration record shows orders for:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 report skin alterations, identify an unstageable pressure injury prior to developing and failed to protect a resident's heel from developing a stage 2 pressure injury. This applies to 2 of 5 residents (R137 and R118) reviewed for pressure injuries in the sample of 30. The findings include: 1. R137's face sheet lists her diagnoses to include: senile degeneration of the brain, dementia, cognitive communication deficit and need for assistance with personal care. On November 18, 2024 at 9:46 AM, V13 Wound Care Nurse (WCN) was changing R137's dressing on her coccyx. R137 had an approximately a dime size elongated open area to her coccyx. V13 stated, it was approximately 1 centimeter deep. R137's initial wound assessment dated [DATE] shows, a pressure ulceration, facility acquired, unstageable measuring 3 cm (centimeters) X 5 cm X unknown to her coccyx. Current plan & Comments: noted by nursing staff, presents as an unstageable PI (pressure…
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.
- Potential for harm · Dcited before2024-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, interview, and record review the facility failed to monitor a resident on the toilet with a history of falls. This applies to 1 of 30 (R10) reviewed for safety supervision in the sample of 30. The findings include: 1. On 11/17/2024 at 2:20PM, shouts of Help me and Help were heard from the hallway. R10 was observed sitting on her bathroom toilet holding the grab bar to the right of toilet. No staff observed in R10's room, bathroom, or outside in the hallway. On 11/17/2024 at 2:28PM, V17 (Agency Certified Nursing Assistant/CNA) said she put R10 on the toilet. V17 said R10 is not alert and oriented. On 11/17/2024 at 2:23PM, V16 (CNA) said staff assist R10 to the toilet. V16 said, We should not leave [R10] on the toilet by herself because she is a fall risk and it's a safety issue. On 11/17/2024 at 2:31PM, V18 (Licensed Practical Nurse/LPN) said, We do not leave [R10] on the toilet alone because she's a fall risk. R10's Fall Risk Evaluation dated 4/1/2024 shows a fall risk score of 15. A score of 8 and above is considered high fall risk according to the Fall Risk…
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.
- Potential for harm · Dcited before2024-11-20 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 interview, and record review the facility failed to provide catheter care interventions to a resident (R119) with a history of urinary tract infection (UTI). This applies to 1 of 5 (R119) residents reviewed for catheters in the sample of 30. The findings include: 1. On 11/17/2024 at 12:05PM, R119 was observed lying in bed with a urinary catheter in place hanging on the side of his bed. On 11/19/2024 at 12:16PM, V2 (Director of Nursing/DON) said catheter care, catheter flush, and betadine should be applied every shift for R119 as ordered and documented. V2 said this is done to help prevent infection. R119's Treatment Administration Record (TAR) dated 11/1/2024 to 11/30/2024 shows an order for Betadine External Solution 10% - apply to external meatus topically every shift. No documentation provided for November 15 and 16, 2024 at 9:00AM. R119's Treatment Administration Record (TAR) dated 11/1/2024 to 11/30/2024 shows an order to flush foley catheter every shift with 60cc (cubic centimeters) of saline. No documentation provided for November 15, 2024 at 9:00AM. R119's Treatment…
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.
- Potential for harm · Dcited before2024-11-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure there were no discrepancies between physical doses of controlled medications (including methadone) and the correlating number documented on the record of controlled substances for 1 of 30 residents (R62) in the sample of 30 reviewed for pharmacy services. The findings include: On 11/18/24 at 9:05 AM, during medication administration observations, there were 22 physical doses of R62's methadone available. R62's Individual Controlled Substance Record (date received 11/12/24) showed there should have been 23 physical doses of methadone. When V19 ( Registered Nurse) administered R62's prescribed dose of methadone, she wrote in 23, skipped that entry and signed out her dose on the next line. There was no entry made for the 23rd dose. On 11/18/24 at 9:40 AM, V19 said the off-going and the oncoming nurses do a count of the narcotics at every change of shift. V19 said they need to make sure there are no medications missing and they need to make sure the count is accurate. V19 said she will need to report 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.
- Potential for harm · D2024-11-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed after being agreed upon by the physician for 1 of 5 residents (R94) reviewed for psychotropic medications in the sample of 30. The findings include: R94's Consultant Pharmacist Recommendation to Prescribed dated 8/2/24 shows the pharmacist requested R94's psychotropic medications, quetiapine and Sertraline, be reevaluated and considered for a gradual dose reduction (GDR). The physician response dated 9/24/24 shows the physician agrees with the recommendations. R94's Order Summary Report dated 11/20/24 shows R94 had an order on 4/4/24 for Sertraline 50 milligrams (mg) once a day and an order on 3/25/24 for Seroquel (quetiapine) 12.5 mg twice a day. There were no orders for the two medications at a reduced dose. On 11/20/24 at 10:30 AM, V25 (Psychotropic Nurse) said the pharmacist reviews the residents' medications and emails the recommendations to her and other leadership personnel in the facility. V25 said she is responsible to address the psychotropic medication…
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.
- Potential for harm · D2024-11-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 interview and record review, the facility failed to ensure psychotropic medication doses were reduced for 1 of 5 residents (R94) reviewed for unnecessary psychotropic medications in the sample of 30. The findings include: R94's Consultant Pharmacist Recommendation to Prescribed dated 8/2/24 shows the pharmacist requested R94's psychotropic medications, quetiapine and Sertraline, be reevaluated and considered for a gradual dose reduction (GDR) as Sertraline may cause drowsiness and Seroquel (quetiapine) may lead to falling and may cause hypotension. The physician response dated 9/24/24 shows the physician agrees with the recommendations. R94's Order Summary Report dated 11/20/24 shows R94 has a current order for Sertraline 50 milligrams (mg) once a day and a current order for Seroquel (quetiapine) 12.5 mg twice a day. R94's Medication Administration Record (MAR) for 9/1/24 to 9/30/24 shows R94 was receiving Sertraline 50 mg daily and Seroquel 12.5 mg twice a day. R94's Medication Administration Record (MAR) for 10/1/24 to 10/31/24 shows R94 was receiving Sertraline 50 mg…
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.
- Potential for harm · D2024-11-20 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 a resident's medications were labeled and stored for 1 (R123) of 30 residents reviewed for medication storage in the sample of 30. The findings include: R123's Order Review Report dated November 18, 2024 shows she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, malnutrition, major depressive disorder, other psychotic disorder not due to a substance or known physiological condition, heart failure, rheumatoid arthritis, bilateral primary osteoarthritis of knee, non-infective gastroenteritis and colitis, sepsis, post-traumatic stress disorder, and cognitive communication deficit. R123's Medication Administration Record shows R123 is prescribed atorvastatin for high cholesterol, citalopram for depression, clopidogrel for clot prevention, ferrous sulfate for supplementation, furosemide for diuresis, metoprolol for hypertension, prednisone for rheumatoid arthritis and inflammation, divalproex for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-20 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 perform hand hygiene and change their gloves during perineal care in a manner to prevent cross contamination for two of five residents (R80, R137) reviewed for infection control in the sample of 30. The findings include: 1. R80's Order Review Report dated November 18, 2024 shows she was admitted to the facility on [DATE] with diagnoses including history of covid, urinary tract infection, obesity, malignant neoplasm of cervix, need for assistance with personal care, pressure injury of right buttock and sacral region. R80's MDS (Minimum Data Set) dated September 23, 2024 shows R80 is dependent on staff for personal and toileting hygiene. R80 is always incontinent of bowel and bladder. On November 18, 2024 at 1:21 PM, V5 and V7 CNAs (Certified Nursing Assistants) performed perineal (peri) care for R80. There was stool noted to R80's front peri area. V7 wiped the stool from R80's front peri area then touched R80's body to help her to turn onto…
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.
- Potential for harm · D2024-11-20 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a resident was not prescribed an unnecessary antibiotic. This applies to 1 of 5 residents (R128) reviewed for unnecessary medications in the sample of 30. The findings include: R128's medication administration record for November 2024 shows, Keflex Oral Capsule 250 MG (milligrams) (cephalexin) Give 250 mg by mouth two times a day for Recurrent UTI (urinary tract infection) prophylaxis. Start Date 03/29/2024. On November 20, 2024 at 1:49 PM, V3 (Assistant Director of Nursing) stated, R128 was on the medication for recurrent UTI's. R128's progress notes do not show any physician notes about starting the medication until November 20, 2024. The progress note shows, .recurrent UT (urinary tract), keflex daily, follow up urology . The facility did not provide any other documentation prior to November 20, 2024. The facility's McGreer criteria infection surveillance checklist dated August 8, 2024 shows, Statement: The facility will utilize the McGreer Criteria Checklist as a valuable infection prevention and control program…
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.
- Potential for harm · Dcited before2024-04-08 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect residents' right to be free from resident to resident physical abuse. This applies to 2 of 3 residents (R2 and R3) reviewed for abuse in the sample of 3. The findings include: R1's face sheet showed R1 was a [AGE] year old female with the diagnosis of dementia with other behavioral disturbance and major depression disorder. R1's diagnoses did not include a diagnosis of a neurological disease with involuntary movements. On 4/8/24 at 9:46 AM, V7 (Registered Nurse- RN) said she was taking care of R1 on 3/16/24. R1 said V8 (Certified Nursing Assistant- CNA) reported to her that R1 had, .hit . two residents with her hands. V7 said the two residents that were hit by R1 were R2 and R3. On 4/8/24 at 9:48 AM, V8 said she did not witnessed the event of R1 hitting R2 and R3. V8 said V10 (CNA) witnessed the event. V8 said V10 reported that R1 slapped R2 and hit R3 with a fist. On 4/8/24 at 2:31 PM, V10 said on 3/16/24, R1 was in the dining room. V10 said R1…
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.
- Potential for harm · F2023-10-25 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 interview and record review, the facility failed to test and record the concentration level of the sanitizer in the third sink of the three compartment sink five of the 12 days reviewed. This failure has the potential to affect all 158 residents residing in the facility. The findings include: During the initial tour of the kitchen on 10/23/23 at 9:30 AM, V15, Dietary Manager, said they check the chemical concentration level in the third sink three times a day after each meal service before washing the dishes. No sanitizer concentration level was recorded for the third sink of the three compartment sink for 10/23/23 and a copy of the Sanitizer Dispenser Log was requested at 9:58 AM. After receiving a copy of the log at 10:02 AM, a concentration level for 8:00 AM on 10/23/23 was present. However, after reviewing the rest of the log for the dates of 10/12/23 through 10/23/23, there was no data recorded on 10/13/23, 10/14/23, 10/18/23, 10/20/23 or 10/22/23. The facility's Kitchen Policy (revised 7/23/23) shows the third sink of the 3 Compartment Sink (Wash, Rinse, Sanitize) 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.
- Potential for harm · Fcited before2023-10-25 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 have an effective system in place to test staff and residents for COVID-19 during a facility outbreak, failed to ensure a resident exhibiting COVID-like symptoms was tested, separated, and isolated, and failed to ensure staff wore the required PPE (personal protective equipment) when caring for residents with COVID-19. These failures have the potential to affect all 158 residents residing in the facility. The findings include: 1. The facility's Daily Census dated 10/23/23 shows there are 158 resident residing in the facility. At 9:00 AM on 10/23/23, there were 27 residents residing in all three units/floors of the facility positive for COVID-19 on droplet/contact isolation. By 10/24/23, there were 41 COVID positive residents in the facility. On 10/24/23 at 2:22 PM, V3, Infection Prevention Nurse/Memory Care Manager, said their current COVID-19 outbreak started on 10/19/23 with R76 on the third floor. R76 had vomiting and weakness 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.
- Potential for harm · D2023-10-25 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure residents were treated in a dignified manner for 2 of 31 residents (R152, R459) reviewed for dignity in the sample of 31. The findings include: 1. On 10/23/23 at 9:40 AM, R152 was in bed watching television. A urinal with 400 mls (milliliters) of urine was hanging from the left upper side rail of R152's bed. R152 stated he was currently non-weight bearing due to bilateral lower leg fractures he sustained in a car accident in September 2023. R152 stated, I can't get up and go to the bathroom right now. I hate having this (urinal) hang here. It's kind of gross. It makes me feel uncomfortable. What if I had visitors? They don't empty it unless I ring the bell and ask them too. 2. On 10/23/23 at 9:00 AM, R459 was alone in her room. A bed pan full of liquid brown stool was noted on the floor next to R459's bed. R459 looked down at the bed pan, pointed to the pan, and stated, Yuck! On 10/24/23 at 11:45 AM, V2 Director of Nursing stated all residents should be treated in a dignified manner. V2 stated 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.
- Potential for harm · Dcited before2023-10-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide fingernail care to a resident that required extensive assistance with personal hygiene for 1 of 31 residents (R20) reviewed for activities of daily living in the sample of 31. The findings include: R20's admission Record showed R20 was [AGE] years old and did not indicate R20 was a diabetic. On 10/23/23 at 11:52 AM, R20 was in bed. R20's fingernails extended about 1/8-1/4 of an inch past the tip of her fingers. There was dark brown debris under the nails. The thumb nail of R20's right hand appeared thick and dark in color. R20 said she hated to look at her nails because they were too long and dirty. R20 said she has always had short nails and having her nails long, bothers her. R20 could not recall when her fingernails were last trimmed. R20 used a finger nail of her right hand to clean under the nails on her left hand. R20 was able to remove some brown debris from under her nails. R20's Restorative UDAs document dated 8/4/23…
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.
- Potential for harm · Dcited before2023-10-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure wounds were assessed, documented, and treatment orders were placed upon identification of a new wound and failed to ensure a wound dressing was changed daily, as ordered, for 1 of 31 residents (R58) reviewed for quality of care in the sample of 31. The findings include: On 10/23/23 at 10:03 AM, R58 was laying in bed. R58 had a gauze wrap on his right lower extremity dated 10/21/23. R58 had an undated bandage on his right leg below his right knee. R58 had an undated dressing to his buttocks. R58 had an undated bandage to his right 2nd toe. On 10/23/23 at 11:50 AM, V6 (Wound Registered Nurse) and V13 ( Wound Licensed Practical Nurse) performed dressing changes to R58. V6 removed the dressing to R58's buttocks. There was a small open area on his left buttock measuring 1.2 centimeters (cm) x 1.20 cm x 0.10 cm. V6 stated, This is new to me, I did not know about this one. The dressing that was below R58's right knee was removed. There was an open area measuring 1.3 cm x 1 cm x 0.10 cm. V6 stated, I did know…
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.
- Potential for harm · Dcited before2023-10-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure injury interventions were in place for 3 of 8 residents (R458, R457, R37) reviewed for pressure injuries in the sample of 31. The findings include: 1. R458's admission physician progress note dated 9/28/23 showed R458 was admitted to the facility, from the hospital, where she was treated for an infected wound to her right hip. R458's wound reports dated 10/23/23 showed the following: a) R458's stage 4 right hip pressure injury measured 3.0 cm (centimeters) x 2.7 cm x unknown. b) R458 was admitted with a stage 3 pressure injury to her coccyx area. The coccyx wound currently measured 5.0 cm x 1.0 cm x 0.1 cm. c) R458 was admitted with an unstageable pressure injury to her right medial ankle. The ankle wound currently measured 2.0 cm x 2.0 cm x unknown. R458's physician order dated 10/17/23 showed the dressing to R458's right hip pressure injury was to be changed daily. On 10/23/23 at 10:39 AM, R458 was in bed. Green, cloth,…
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.
- Potential for harm · Dcited before2023-10-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 facility staff failed to maintain a resident's indwelling urinary catheter bag below the level of the resident's bladder and off the floor for a resident with a urinary tract infection (UTI) for 1 of 5 residents (R459) reviewed for urinary catheters in the sample of 31. The findings include: R459's admission Record dated 10/21/23 showed R459 was readmitted to the facility on [DATE] with an indwelling urinary catheter in place and a diagnosis of UTI. On 10/23/23 at 9:10 AM, V5 Certified Nursing Assistant (CNA) stood at R459's bedside as R459 attempted to reposition herself in bed. V5 CNA unhooked R459's indwelling urinary catheter bag from the side of the bed and lifted the bag up to the level of his waist (above the level of R459's bladder), as R459 lay in bed. A backflow of urine was noted from the catheter bag towards R459. As V5 CNA continued to hold the catheter bag at the level of his waist (above R459's bladder), V5 CNA used his other hand to assist R459…
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.
- Potential for harm · D2023-10-25 · tag F0744 — failed to care for residents with dementia — isolatedProvide 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 a resident with a diagnosis of dementia received the necessary care and services for behaviors of wandering. This applies to 1 of 4 residents (R124) reviewed for dementia care in the sample of 31. The findings include: 1. R124's face sheet shows she is a [AGE] year old female with a diagnosis including dementia, unspecified severity with agitation, anxiety disorder, insomnia, neuromuscular dysfunction of bladder. R124's Minimum Data Set assessment dated [DATE] shows her cognition is severely impaired, no behaviors of psychosis, no rejection of cares and no wandering behaviors. Her activity preferences responded by R124 shows it's very important for her to listen to the music she likes, do her favorite activities and to do things with groups of people. On 10/23/23 at 9:32 AM, R124 was observed leaving room [ROOM NUMBER] (another resident's room) and wandering the halls. At 9:42 AM, R124 opened the door and entered R29's room while…
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.
- Potential for harm · Dcited before2023-10-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure prescription medications were administered according to standards of practice for 1 of 31 residents (R456) reviewed for medication administration in the sample of 31. The findings include: On 10/23/23 at 2:05 PM, R456 was in bed asleep. V10 (Family of R456) was seated in a chair next to R456's bed. When this surveyor asked V10 if R456 had received any pain medication recently, V10 stated, I don't know but what is this? The nurse dropped this off. She told me to give it to (R456) when he wakes up. V10 handed this surveyor a small plastic medication cup that contained one beige oblong capsule. The medication cup, containing the capsule, was shown to V7 Registered Nurse (RN). V7 RN stated, That's (R456's) Gabapentin (nerve/pain medication). He was sleeping when I went to give it to him, so I left it with (V10 Family of R456) to give to him when he woke up. R456's physician order dated 10/21/23 showed R456 was to receive Gabapentin 300 mg (milligrams), by mouth, daily at 9:00 AM, 1:00 PM, and 9:00 PM. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-25 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 all residents were offered and/or received the influenza and/or pneumococcal immunizations for 3 of 5 residents (R118, R122, R16) reviewed for immunizations in the sample of 31. The findings include: On 10/24/23 at 10:57 AM, V3, Infection Prevention Nurse/Memory Care Manager, said they review the residents' vaccination status on admission and with their care plan meetings quarterly. V3 said Pneumococcal vaccinations are offered to residents on admission and quarterly with their care plan meetings. On 10/25/23 at 10:52 AM, V3 said they started offering the Influenza vaccine to the residents after receiving it on 10/13/23. R118, R122, and R16's Immunization records and applicable consent/refusal forms provided by the facility were reviewed. No Pneumococcal vaccination refusal forms for these three residents were provided by the facility. R118's Immunization record printed on 10/24/23 shows he currently resides on the second floor of the facility. There is no record a Pneumococcal vaccination was ever received 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.
“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.
- 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.
Fines & penalties
$96,025 in federal fines across 3 penalties. 2 Medicare payment denials on record.
- $14,050 — penalty dated 2024-11-04
- $50,778 — penalty dated 2024-11-04
- $31,197 — penalty dated 2023-10-25
- Medicare payment denial — starting 2024-11-27 for 21 days
- Medicare payment denial — starting 2023-11-17 for 4 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 LEGACY HEALTHCARE — 89 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 4 of 5 | 3.3 | +0.7 vs chain |
The other 88 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 88; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DOROS GENERATION TRUST U/A/D 1/3/12 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 17% | since 06/01/2021 |
| GPN FAMILY TRUST U/A/D 4/28/08 | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 17% | since 06/01/2021 |
| GARDEN, DANIEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 59% | since 06/01/2021 |
| NINIO, MORDECHAY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 8% | since 06/01/2021 |
| LEE, JASON | Individual | W-2 MANAGING EMPLOYEE | — | since 06/01/2021 |
| TBDMD IL, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 06/01/2021 |
3 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.
This home reported $334K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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
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.
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 145678. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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.