Fair Oaks Rehab & Healthcare

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

50.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 85 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 32.6% 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 43 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 0.28 therapist hours per resident per day in 2026Q1 — more than 42% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 35% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 78 beds and averages 59.1 residents a day — about 76% occupied, or roughly 19 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.99 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 3.01 hrs/resident/day on weekends vs 3.60 on weekdays — 16% thinner on weekends. RN hours go from 0.85 to 0.47 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

36 citations, most serious first. The 14 most serious are shown; the remaining 22 are one tap away and print in full.

• Immediate jeopardy · J2026-03-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect a cognitively impaired resident (R7) from sexual abuse by another resident with a known pattern of sexually inappropriate behaviors. R8 was observed with his hand on R7's thigh moving towards her genital area. This failure applies to two of three residents (R7, R8) reviewed for abuse in the sample of 8 and resulted in Immediate Jeopardy.The Immediate Jeopardy began on 3/2/2026 when R8 was observed with his hand on R7's lap moving up towards her private area. V1 (Administrator) was notified of the Immediate Jeopardy on 3/5/2026 at 3:18 PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 3/6/2026, but noncompliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:The facility face sheet shows R7 was admitted to the facility on [DATE], with diagnoses to include hemiplegia…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-02-11 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident (R9) found not breathing and pulseless whose physician's order showed the resident was a Full Code. This failure led to a delay in R9 receiving CPR and R9 dying in the facility. This applies to 1 of 3 residents (R9) reviewed for death in the sample of 14. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:40 PM, when facility staff failed to immediately initiate CPR on R9 when she was found unresponsive and pulseless. This failure resulted in R9 receiving CPR 42 minutes after being found unresponsive and pulseless, which resulted in R9 dying in the facility on [DATE]. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:13 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on [DATE], prior to the start of the survey and was therefore Past…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2026-04-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident experiencing nausea and loose stools during a salmonella outbreak was considered for salmonella infection. This failure resulted in R6 experiencing loose stools with nausea for a week before being sent to the local hospital for salmonella and sepsis. This applies to 1 of 6 residents reviewed for infection control in the sample of 6.The findings include:Per email communications with V1 (Administrator) on 4/7/26, V1 stated R4 and R6 were roommates from 2/14/26 until 3/21/26, when R6 was discharged to the local hospital. R4's hospital records from 10/21/25 show R4 was positive for salmonella before discharging to the facility on [DATE].R6's progress note from 3/14/26 shows R6 presented with nausea and loose stools during the morning shift. R6's progress note from 3/14/26 shows R6 continued to experience loose stools during the evening shift. R6's progress note from 3/17/26 from V13 (Nurse Practitioner) states R6 was seen…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess and monitor a change of condition for a resident following surgical repair of left humerus fracture. This failure resulted in R1 sustaining a new fracture to her left distal humerus shaft discovered on her outpatient appointment on 1/29/25 (nine days after admission) and requiring new surgical intervention. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 14. The findings include: R1's face sheet shows she is an [AGE] year old female admitted to the facility on [DATE], with diagnoses included unspecified fracture of shaft of humerus left arm, orthopedic aftercare, cognitive communication deficit, aphasia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and primary osteoarthritis. R1's Final Incident Report, dated 1/31/25, documents (R1) was admitted on [DATE], post fall with left humerus fracture status post nailing on 1/14/25. R1 had an ortho follow up appointment on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-10 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to have isolation signs on the doors of two residents on isolation. This applies to 2 of 3 residents (R2,R3) reviewed for infection control in the sample of 8.The findings include: The facility face sheet for R2 shows she was admitted to the facility with diagnoses to include Parkinson's, surgical site aftercare and urinary tract infection. The facility assessment, dated 12/17/2025, shows R2 to be cognitively intact and requires moderate assistance with her activities of daily living. A Physician order dated 12/12/2025 shows an order for enhanced barrier precautions.The facility face sheet for R3 shows he was admitted to the facility with diagnoses to include surgical aftercare, pressure ulcers, type 2 Diabetes, and wound infections. The facility assessment, dated 1/22/2026, shows him to be cognitively intact and requires partial assistance with his activities of daily living. A Physician order, dated 11/4/2025, shows R3 is to be on contact isolation. A care plan, dated 11/6/2025 with a revision date of…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to perform incontinence care for a dependent resident (R3). This applies to 1 of 3 residents reviewed for incontinence care in the sample of 7.The findings include:R3's electronic face sheet, printed on 12/12/25, showed R3 has diagnoses including but not limited to Lennox-Gastaut Syndrome, Epilepsy, autistic disorder, and severe intellectual disabilities.R3's facility assessment, dated 11/24/25, showed R3 has severe cognitive impairment, incontinence of urine and bowel, and dependent on staff for personal hygiene.R3's care plan, dated 8/19/25, showed, (R3) has bladder incontinence due to cognitive impairment and impaired mobility .provide perineal care after each incontinent episode, check frequently for incontinence .On 12/12/25 at 10:10AM, V4 (Certified Nursing Assistant-CNA), V6 (CNA), and V5 (Licensed Practical Nurse-LPN) provided incontinence care for V3. V4 removed R3's toy off his lap and revealed a large wet area on the front of R3's pants. V4 stated R3 got up around 6:30AM and has not been changed since…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-10 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to assess a resident's need for siderails for positioning/bed mobility before removing them for 4 of 16 residents (R47, R42, R26 and R23) reviewed for accommodation of need in the sample of 16. The findings include:1.On 9/8/25 at 10:00 AM, R42 was lying in bed. R42 did not have siderails or assist bars on his bed. V26 (R42's Father) said he is upset the facility came in about a week or so ago and took his siderails off. V26 said R42 would use his siderails to help turn in bed, and it was good therapy for him. R42's Rehab Data Report, dated 8/18/25, shows diagnosis of: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R42 requires substantial/maximal assistance to roll from left to right while in bed. On 9/9/25 at 3:01 PM, V2 (Director of Nursing) said everyone in the whole building had siderails, and they went around and removed all of them due to risk for entrapment. V2 said their plan is to have therapy assess each resident to determine their need for siderails 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-10 · tag F0805 — failed to prepare food in a form residents can eat — pattern
  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure the pureed meal was prepared in a smooth consistency. This applies to 6 of 6 residents (R49, R56, R65, R20, R33, R42) reviewed for therapeutic diets in the sample of 16. The findings include: On 09/08/25 at 10:08 AM, V6 (Cook) placed seven hamburger patties in the food processor, added seven scoops of thick processed cheese product, and blended. V6 then added three additional hamburger buns and three scoops of liquid broth, blended, and then added four more buns and several additional scoops of liquid broth. The food processor was full to the brim of the puree cheeseburger. V6 and V5 (Dietary Manager) sampled the pureed cheeseburger and V5 stated, I think a little more blending and maybe blend half of it at a time. V6 did not remove 1/2 of the puree meal from the food processor and continued to blend the pureed cheeseburger approximately 30 more seconds and then sampled the puree and said, it's good and placed it in the steam tray. On 09/08/25 at 12:15 PM, a sample tray of the pureed meal was provided.…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-10 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a resident was assessed to be able to self-administer medications. This applies to 1 of 16 residents (R50) reviewed for medication self-administration in a sample of 16.The findings include:On 9/8/25 at 9:35 AM, R50 was talking with a visitor. R50 used an inhaler and placed the inhaler in a lock box on their nightstand. R50 stated she had been storing it in the box for a while.R50's Physician Orders showed an order for Albuterol-Budesonide Inhalation Aerosol 90-80 to be given 1 puff inhaled orally every 4 hours as needed for shortness of breath related to chronic obstructive pulmonary disease. There is no physician order for R50 to self-administer the inhaler.R50's medical record showed no assessment or care plan pertaining to self-administering medications at the time of the survey.On 9/10/25 at 8:30 AM, V2, Director of Nursing, stated residents need to be assessed, care planned, and have a physician order to self-administer medications.The facility's Self-Administration of Medication Policy, dated…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a Stage III pressure wound was assessed for 1 of 4 residents (R1) reviewed for pressure wounds in the sample of 16.The findings include:On 9/8/25 at 9:55 AM, R1 was observed to have dressing to her right posterior thigh. R1 said it was not caused by her accident; her skin splits there sometimes.On 9/9/25 at 10:10 AM, V4, Wound Care Nurse, said if there a new skin condition, the CNA (Certified Nursing Assistant) will notify the nurse, and the nurse will assess it and notify her. V4 said she will assess it as soon as she is informed, usually the same day, sometimes the next day, but within 24 hours. V4 said she is aware of R1's right posterior thigh wound. V4 said she did not do an assessment and did not document the wound measurements. On 9/9/25 at 11:34 AM, V25, said R1's right posterior thigh wound is a pressure ulcer. V25 said it goes from open to healed frequently, and was closed for a long time. V25 said every time is reopens, it remains a Stage III pressure ulcer. R1's Skin Check Weekly & PRN…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement nutritional interventions for a resident who is underweight for 1 of 5 residents (R12) reviewed for nutrition in the sample of 16. The findings include: R12's Face Sheet shows that she admitted to the facility on [DATE], with a diagnosis of moderate protein-calorie malnutrition and dementia. R12's Weights and Vitals Summary shows a weight of 77 pounds on 8/17/25. R12's Dietitian Note dated 8/19/25 shows, Resident screened for malnutrition, at risk per MNA score.Varied intake at meals, consuming 25-100% per chart review. Current weight: 77#. BMI (Body Mass Index): 14.1, underweight.REC (recommendations): MedPass 60 mL (milliliters) TID (three times a day) between meals for varied PO (oral) intake / underweight.R12's Nutrition Diagnosis Criteria Form, dated 8/19/25, show 2 Cal Med Pass of 60 mL three times a day is recommended as a nutritional intervention. This recommendation was signed as approved by the provider. R12's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-10 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a resident received pain medication as ordered to achieve adequate pain control for 1 of 16 residents (R60) reviewed for pain management in the sample of 16. The findings include: R60's Face Sheet shows diagnoses of: chronic pain, pain in left foot, ankle and joints, bone transplant, osteoarthritis of left foot and ankle, dislocation of tarsal joint of left foot, contracture of left foot, non-pressure chronic ulcer of left foot, joint disorder of left ankle and foot, and aftercare following joint replacement surgery.R60's September Medication Administration Record shows an order for oxycodone 5 mg (milligrams)-1-2 tablets every 4 hours as needed for pain, 1 tablet for pain from 1-5, 2 tablets for pain 6-10. R60's Oxycodone Controlled Substance Sheet shows from 9/3-9/6, R60 took 10 tablets of oxycodone daily. The sheet shows on 9/7 at 4:20 PM, she had only 7 pills left. R60's Care Plan shows she has pain due to: status post left achilles Tenotomy, presence of external fixator, left ankle contracture 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-10 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure 1 of 16 residents (R46) ingested their medications in the sample of 16 residents reviewed for pharmacy services.The findings include:On 9/8/25 at 10:36 AM, R46 was lying in bed on his left side. Two pills were on his bed covers. On 9/8/25 at 10:42 AM, V24, Registered Nurse (RN), said the nurse should always watch to make sure a patient swallows their medications. V24 approached R46's bed and removed the two pills from his linens. The facility's Medication Administration Policy for Senior Living (undated) shows staff members must ensure that residents have swallowed or otherwise received the medication properly.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-10 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure pharmacy recommendations were addressed and/or implemented for 1 of 5 (R23) residents reviewed for monthly medication review in the sample of 16. The findings include: The findings include:On 9/9/25 during the morning medication pass which began at 8:23 AM, V31, Licensed Practical Nurse/LPN administered R23 Trelegy Ellipta via inhalation. V31 did not instruct or encourage R23 to rinse her mouth following the inhaled medication.R23's Pharmacy Medication Regimen Review, dated 7/20/25, shows the following: Resident has an order for the following inhaled corticosteroid: Trelegy Ellipta. To prevent oral candidiasis (thrush) caused by the inhaled corticosteroid, ensure the resident rinses their mouth with water (swish and spit) after each inhalation. Please consider adding this to the order on the MAR (Medication Administration Record). On 9/10/25 at 11:05 AM, V2, Director of Nursing (DON), said once the pharmacy reviews the residents medications, they get the recommendations the next day. They present the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$71,124 in federal fines across 3 penalties. 1 Medicare payment denial on record.

• $48,590 — penalty dated 2026-03-10
• $8,161 — penalty dated 2025-02-11
• $14,373 — penalty dated 2025-02-11
• Medicare payment denial — starting 2026-03-31 for 13 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 TUTERA SENIOR LIVING & HEALTH CARE — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

CMS files one row per role, so the 22 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

6 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 $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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