South Elgin Living & Rehab Center
746 West Spring Street, South Elgin, IL 60177 · For profit - Limited Liability company · 90 certified beds · (847) 697-0565 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- lower-than-typical staff turnover (24% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jul 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (49) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $231,656 in federal fines (most recent 2025-07-08)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 held steady at 1 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 | 10.1% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.3% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 94.5% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.5% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.2% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.1% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.3% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.1% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.6% | 21.7% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.63 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.90 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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.
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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 8.3–18.0 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 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 90 beds and averages 56.0 residents a day — about 62% occupied, or roughly 34 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.81 hrs/resident/day on weekends vs 3.33 on weekdays — 16% thinner on weekends. RN hours go from 1.06 to 0.87 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 24% is below 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.
49 citations, most serious first. The 14 most serious are shown; the remaining 35 are one tap away and print in full.
- Immediate jeopardy · K2024-02-01 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 maintain a safe, clean, comfortable homelike environment following the disruption of water services due to broken pipes in the facility. The failure resulted in a lack of available handwashing facilities and the accumulation of human feces/urine in the toilets. The lack of response caused a risk for psychosocial harm to residents as evidenced by their disgust for having to eliminate in toilets full of urine/feces and subsequently not have hand washing facilities available to wash hands. This applies to 35 of 60 residents (R2, R4, R8, R10-R13, R15-R17, R19-R23, R25, R26, R30-R32, R35, R40, R41, R43-R51, R58, R59 R60) reviewed for homelike environment who could utilize facility bathrooms/toilets in a sample of 61. The Immediate Jeopardy began on 1/17/24 at 9:30 PM when the initial water pipe break occurred. V1 (Acting Administrator), V2 (Director of Nursing), V3 (Regional Director of Operations), and V7 (Division Director of Operations) 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.
- Actual harm · G2025-07-08 · 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 observation, interview, and record review, the facility failed to prevent resident-to-resident physical abuse. This applies to 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 3. This failure resulted in R2 striking R1 on the nose, resulting in R1 being transferred to the hospital and found to have a fractured nose.Findings include:R1's Face Sheet shows R1 admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, mild intellectual disability, and bipolar disorder. R2's Face Sheet shows R2 admitted to the facility on [DATE] with diagnoses including diabetes, seizures, and depression. The facility's 6/19/25 Final Incident Investigation Report shows an incident between R1 and R2 occurred on 6/15/2025 (Sunday) at approximately 5:15 PM. The report showed, the R1 and R2 were roommates and resident-to-resident contact was reported. The report shows R1 and R2 had a disagreement over the thermostat in the room and that R2 struck R1 on the bridge of his nose, which resulted…
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 · G2024-05-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician's orders for psychotropic medication administration (R36). The facility failed to follow its psychotropic medication policy by failing to monitor residents (R1, R14, R36) for Extrapyramidal Symptoms due to antipsychotic medication use and failing to attempt/request a Gradual Dose Reduction of a Benzodiazepine medication for a resident (R14) no longer exhibiting anxiety behaviors. These failures resulted in the R36 receiving the wrong psychotropic medications and at excessive dosages. R36 experienced side effects of increased abnormal involuntary movements. This applies to 3 of 5 residents (R1, R14, and R36) reviewed for psychotropics in a sample of 19. The findings include: 1. R36's Medical Record (MR) showed R36 was receiving psychiatric care for major depression, anxiety, and insomnia. R36's MDS (Minimum Data Sheet) dated 5/02/2024 showed R36 was cognitively impaired and did not show any mood symptoms such as feeling…
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 before2024-04-25 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain orders and provide physical therapy services to residents. This failure resulted in a resident with a functional decline (R103) having a delay in receiving physical therapy and taking longer to return to his baseline function. This applies to 3 of 3 residents (R101, R102, and R103) reviewed for therapy services in the sample of 9. The findings include: 1. R103's Medical Record showed R103 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, epilepsy, dementia, and nontraumatic subarachnoid hemorrhage. R103's MDS (Minimum Data Set) dated January 28, 2024, showed R103 had moderate cognitive impairment. The MDS continued to show R103 could independently transfer to and from a bed to a chair, toilet transfer, and walk 150 feet. A progress note dated February 26, 2024, at 4:30 AM, by V18 (RN/Registered Nurse) showed, resident awake and alert, verbally responsive. Breathing non labored and 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 · Fcited before2025-08-14 · 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 observation, interview and record review, the facility failed to maintain freezer temperatures, failed to follow food temperature guidance for foods stored in the steam table, and failed to store dented cans per facility policy. This applies to all 56 residents that receive foods prepared in the facility kitchen.Findings include:1. On August 11, 2025, at 9:42 AM, the initial tour of kitchen was completed in the presence of V4 (Dietary Manager). In the dry storage room there were 3 cans (6 lbs/pounds, 12 oz/ounces each) of cut sweet potatoes in syrup that were dented at the seam. In addition, there was one can (6 lbs, 8 oz) of sliced apples in water that was also dented at the seam. These cans were placed on the shelving that contained other cans of food items. V4 stated that she usually checks the cans on delivery and returns it to the purchased company. In the reach in freezer, the internal temperature gauge showed 10 degrees Fahrenheit and noted that chicken strips (wrapped in clear packaging) and two bags of frozen vegetables (5 lb/bag) were not firm to touch and had ice…
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 before2025-08-14 · 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 follow their water management plan for legionella and perform hand hygiene during wound care.This applies to all 57 residents residing in the facility. Findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated August 11, 2025, showed the facility's census was 57 residents. On August 13, 2025, at 8:59 AM, V10 (Regional Maintenance Director) said for the facility's water management plan for legionella, the facility flushes the two hot water heaters twice a year to prevent legionella from building up inside the tanks because hot water is stored in the tanks. V10 said the annual water test in June 2025, showed a small amount of legionella in one of the shower rooms. V10 said the recommendation was to flush the hot water heaters. V10 said the hot water heaters were last flushed around June 27, 2025. V10 said there is no documentation the hot water heater was flushed. V10 said there is no…
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 · D2025-08-14 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from chemical restraints.This applies to 2 of 5 residents (R4, R10) reviewed for unnecessary psychotropic medications in the sample of 15.Findings include: 1. The EMR (Electronic Medical Record) showed R10 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, major depressive disorder, vascular dementia, and generalized anxiety disorder. R10's MDS (Minimum Data Set) dated May 23, 2025, showed R10 has moderate cognitive impairment. R10's Physician Orders dated August 13, 2025, showed an order dated June 23, 2025, for lorazepam (antianxiety medication) 1 mg (milligram) tablet, give one tablet by oral route every six hours for 14 days as needed. R10's lorazepam order does not show a stop date for the medication. R10's July 2025 MAR (Medication Administration Record) showed R10 received doses of as needed lorazepam on July 8, 9, 10, 12, 17, 18, 19, 22, and 27. R10's August 2025 MAR showed…
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 before2025-08-14 · 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 grooming assistance to remove facial hair for a resident with poor vision.This applies to 1 of 3 residents (R48) reviewed for ADL (activities of daily living), in the sample of 15. Findings include: R48's face sheet included diagnoses of type 2 diabetes mellitus with diabetic neuropathy, blindness left eye category 3, normal vision right eye, blindness, one eye, unspecified eye, dry eye syndrome of bilateral lacrimal glands. R48's quarterly MDS (minimum data set) dated showed that R48 was cognitively intact and required partial moderate assistance (helper does less than half the effort) for personal hygiene. R48's care plan effective November 23, 2024 included that R48 has been observed to need assistance in performing some portion of her ADL dressing and grooming as R48 demonstrated the following areas of deficit: Impaired functional strength, impaired functional endurance, impaired hand grasp/coordination, impaired balance in sitting/standing, impaired functional reach. Interventions included as…
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 · D2025-08-14 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
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 to complete a dressing change for a resident's soiled IV (intravenous) dressing.This applies to 1 of 1 residents (R9) in the sample of 15.Findings include:R9's EMR (Electronic Medical Record) showed R9 was admitted to the facility on [DATE]. R9 was recently hospitalized on [DATE], and was readmitted to the facility on [DATE], with diagnoses of hematuria (blood in urine) and UTI (Urinary Tract Infection). R9's MDS (Minimum Data Set) dated July 4, 2025, showed R9 was cognitively intact. R9's care plan showed R9 was receiving IV (Intravenous) antibiotic therapy for an UTI. Interventions included the nurse was to monitor the IV site every shift and as needed. On August 11, 2025, at 10:13 AM, R9 was in bed. There was a midline IV in his right antecubital (front area of elbow). There was a gauze dressing over the insertion site and a transparent occlusive dressing over the entire site. The dressing was dated as last changed on August 7, 2025. The gauze…
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 · D2025-08-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 secure resident oxygen tanks and failed to maintain and lock storage shed for oxygen tanks.This applies to 2 of 2 residents (R4, R48) reviewed for oxygen storage in the sample of 15.Findings include:1.R48's face sheet included diagnoses of chronic obstructive pulmonary disease, unspecified asthma, dependence on supplemental oxygen. R48's face sheet included diagnoses of malignant neoplasm of unspecified part of unspecified bronchus or lung, chronic obstructive pulmonary disease. R4's physician orders included oxygen at 2-3 liters continuous.On August 11, 2025, at 10:47 AM, R48 was seated in a wheelchair with portable oxygen tank pocket in the wheelchair and stated I am a smoker. They let us out and give me a cigarette. They take out my oxygen tank. On August 12, 2025, at 12:59 PM during smoke break, R48 was handed a cigarette by V7 (Activity Aide). V7 then removed the portable oxygen tank from the back of R48's wheelchair and placed it standing vertically on the floor near the side of the sliding door that led…
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 before2024-09-13 · 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 follow the State Department of Public Health and the Local County Health Department instructions to obtain appropriate facility-wide testing, initiate treatment for a resident (R1) with positive test results, and adhere to the mandated facility-wide masking for the management of their group A streptococcal disease outbreak. This applies to all the residents residing at the facility. Findings include: The facility's resident roaster dated 9/12/2024 showed a census of 56 residents. 1. The CDC (Center for Disease Control and Prevention) website link https://www.cdc.gov/group-a-strep/about/index.html dated 3/1/2024 documents, Group A Streptococcus (group A strep bacteria) can cause serious and deadly clusters or outbreaks. Group A strep bacteria are very contagious. Some people infected with group A strep bacteria don't have symptoms or seem sick. They can still spread the bacteria to others. Generally, people spread the bacteria to others…
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 · D2024-09-13 · tag F0921 — failed to keep a safe, functional, sanitary building — isolatedMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to safely repair an exposed ceiling area located outside residents' (R8, R9, and R10) rooms. This applies to 3 of 8 residents reviewed for environmental hazards. The findings include: On 9/12/2024 at 8:32 AM, during the facility's environmental rounds, there was an open ceiling area with exposed pipes above the entrance of the housekeeping room. The housekeeping room was in the the resident hall in front of R8, R9, and R10's rooms. The cut-out open ceiling area had a loose plastic covering with a moderate amount of drywall debris. The plastic covering was not properly secured it had scattered pieces of blue painter's tape. At 11:45 AM, V4 (Housekeeper Supervisor) said approximately three weeks ago there had been a pipe leak above the housekeeping room entrance area. V4 said the facility did not have maintenance staff available to fix the open ceiling drywall area. V4 said the open ceiling area had remained with the same plastic covering 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 · E2024-08-14 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
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 nurse was competent to administer medications as ordered and transcribe orders for 4 of 4 residents (R3, R4, R7 and R8) reviewed for nursing services in the sample of 8. Findings include: 1. R3's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: polyneuropathy, schizoaffective disorder, neuromuscular dysfunction of the bladder, anxiety, hypothyroidism, insomnia and hyperlipidemia. R3's Minimum Data Set (MDS) assessment dated [DATE] shows that her cognition is intact. R3's August Medication Administration Record (MAR) shows that she takes lamotrigine (anticonvulsant) 25 milligrams (mg)-3 tablets once daily at 8:00 AM for mood stabilization, aripiprazole (antispychotic) 10 mg daily at 8:00 AM for mood and paranoia and gabapentin (anticonvulsant) 300 mg three times a day at 8:00 AM, 12:00 PM and 6:00 PM for anxiety/pain. On 8/13/24 at 10:05 AM, R3 said that V3 (Registered Nurse) gave her her 8:00 AM medication one day…
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 before2024-06-13 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 a Director of Nursing on a full-time basis. This has the potential to affect all 60 residents who reside in the facility. Findings include: On 6/8/24 at 2:52 PM, V1 (Administrator) submitted a resident roster and facility data sheet that showed 60 residents were in the facility. On 6/8/24 at 10:49 AM, surveyor asked V5 (RN-Registered Nurse) that if she can let the DON (Director of Nursing) know that surveyor is in the building. V5 stated, We don't have a DON. It's been some time now. The administrator is on her way. We used to have an ADON (Assistant Director of Nursing), but she is no longer with us. Someone from corporate is helping us. On 6/8/24 at 11:08 AM, V6 (LPN-Licensed Practical Nurse) stated, We don't have a DON here. But we have a regional lady and we have someone from our sister facility that is helping us. On 6/11/24 at 9:15 AM, V1 stated, (V13--Former DON--Director of Nursing) resigned on 3/29/24. Then (V14--2nd Former DON) took over on 3/30/24. (V14) then worked for a couple of weeks. Then…
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 35 citations
- Potential for harm · E2024-06-13 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 observation, interview, record review, the facility failed to provide structured activities to residents. This applies to 7 of 8 residents (R4, R5, R6, R7, R8, R9, R10) reviewed for activities. The findings include: On Saturday 6/8/24 at random times, residents were in the day room or in their rooms without any activities. The following observations were made: 1. On Saturday 6/8/24 at 11:29 AM, R4 stated, There are no activities on the weekend. I would like some. I know they are working on it. Activities are only between Monday through Friday. I have nothing to do. R4's face sheet shows he was admitted [DATE]. R4's face sheet shows diagnoses of anoxic brain damage and depression. R4's MDS (Minimum Data Set) dated 4/4/24 shows a BIMS (Brief Interview for Mental Status) score of 13, which means he is cognitively intact. 2. On 6/8/24 at 11:31 AM, R5 stated, I would like some activities on the weekend. We have not had activities during the weekend in a long time. They don't offer anything. R5's face sheet…
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 before2024-05-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen. This applies to 53 residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Longterm-Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 5/29/24 documents that the total census was 56 residents. On 5/30/24 at 10:14 AM, V2 (DON-Director of Nursing) stated, there are three NPO (Nothing by Mouth) residents that do not eat from the facility kitchen. On 5/28/24 starting at 9:35 AM, the facility kitchen was toured in the presence of V6 (Dietary Manager) and the following was found: 1. Macaroni Elbow pasta, 10 lbs opened bag - no date when it was received, no expiration date. 2. Spaghetti noodles pasta, 10 lbs opened bag - no date when it was received, no expiration date. 3. Macaroni Bow pasta, 10 lbs opened bag - no date when it was received, no expiration…
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 before2024-05-31 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 interview and record review the facility failed to follow a physician's laboratory order for management of anticonvulsant medication. This applies to 1 of 3 residents (R10) reviewed for labs in a sample of 19. The findings include: R10's Medical Record (MR) showed multiple diagnoses including general convulsant epilepsy intractable seizure disorder, encephalomalacia, and encephalitis. R10's MR showed R10 was receiving phenobarbital (anticonvulsant) medication and an order dated 1/31/2024 for phenobarbital trough level laboratory (lab) draw. On 5/29/2024 at 12:54 PM, V3 (Registered Nurse/RN) said R10 was receiving phenobarbital for her seizure disorder and R10's medication blood levels should be monitored as ordered. Surveyor asked V3 to provide R10's last phenobarbital trough level lab draw, V3 said he reviewed R10's labs from present to 11/2023 and was unable to find the lab result. On 5/29/2024 at 3:57 PM, V2 (Director of Nursing/DON) said nurses are expected to follow physician lab orders to monitor blood levels. On 5/29/2024 R10's lab results for the past six months…
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 · E2024-05-31 · tag F0740 — failed to provide behavioral / mental-health care — patternEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
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 follow its policy on behavior monitoring for residents with known behaviors and receiving psychotropic medications. This applies to 5 of 5 residents (R1, R8, R14, R36, and R39) reviewed for behaviors in a sample of 19. Findings include: 1. R1's Medical Record (MR) showed multiple diagnoses including schizoaffective disorder, bipolar disorder, depression, and psychosis. R1's MDS (Minimum Data Sheet) dated 3/13/2024 showed R1 was cognitively impaired and did not show any behaviors such as screaming or public sexual acts. On 5/28/2024 at 10:03 AM, R1 was in bed. R1 was unable to engage in the interview, his speech was incohesive and disorganized. R1 was making inappropriate sexual gestures. On 5/29/2024 at 8:09 AM, R1 was in bed again making inappropriate sexual gestures. R1's care plan reviewed on 5/30/2034 showed psychotropic medication use related to behaviors of aggression, physically abusive, uncontrollable screaming, and auditory…
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 · E2024-05-31 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 medications were available for administration to residents with physician's orders. This applies to 5 out 5 (R5, R13, R23, R30 and R48) reviewed for medication administration. The findings include: 1. On 5/29/2024 at 8:05 AM, during medication pass, V5 (RN-Registered Nurse) said there was no available Ascorbic Acid (supplement) 500 MG (Milligrams) so she could not administer it to R13. V5 said Ascorbic Acid 250 mg and Ascorbic Acid 500 mg were both not available in her medication cart. V5 said there was also no Ascorbic Acid in the medication room and in the small closet they keep the extra house stock in. She said Ascorbic Acid medications were not available since Monday, May 27, 2024. V5 went into the closet where house stocks are stored but did not find any Ascorbic Acid. Review of R13's POS (Physician Order Sheet) showed an order for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. 2. On 5/29/2024 at 8:20 AM, during medication pass, V5 was observed administering a total of six medications to R30 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 · E2024-05-31 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician. There were 37 opportunities with 4 medication administration errors resulting in a 10.81% medication error rate. This applies to 3 out of 4 residents (R13, R19 and R30) reviewed for medication administration in the sample of 19. Findings include: 1. On 5/29/2024 at 8:05 AM, V5 (RN-Registered Nurse) was administering medication to R13. V5 administered the following medications: Fish Oil (supplement) 1000 mg (milligrams), 1 capsule; Allopurinol (Uric Acid Inhibitor) 100 mg, 1 tablet; Daily-vite (supplement), 1 tablet; Divalproex (antiepileptic) Na (Sodium) ER (Extended Release) 250 mg, 1 tablet; Divalproex Na ER 500 mg, 2 tablets; Polyethylene Glycol (stool softener) 17 gm (gram); and Metoprolol (Antihypertensive) 25 mg, 1 tablet. V5 said there was no available Ascorbic Acid (supplement) 500 mg so she could not administer it to R13. V5 said Ascorbic Acid 250 mg and Ascorbic Acid 500 mg were both not available in her medication cart. V5 said there was also no…
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 before2024-05-31 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to wear appropriate Personal Protective Equipment in enhanced barrier precaution rooms. The facility failed to provide proper catheter care and perform hand hygiene during gastrostomy tube care. This applies to 4 of 4 residents (R11, R30, R47, R50) reviewed for infection control in sample of 19. The findings include: 1. On 5/28/24 at 10:41 AM, during initial tour, surveyor went to R47's room. R47 had a G-Tube (Gastrostomy Tube) running and as per the floor nurse V3 (RN-Registered Nurse), R41 also has a pressure sore to his right heel. There was no sign on R47's door about enhanced barrier precautions. On 5/29/24 at 12:20 PM, there were signs posted on R47's door. One sign said, Stop and See Nurse. The other sign showed, Stop! Enhanced Barrier Precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing linens,…
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 · E2024-05-31 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on the interview and record review, the facility failed to utilize a standardized tool to determine the necessity of antibiotic therapy prescribed to residents. This applies to 5 of 5 residents (R10, R12, R22, R50, and R206) reviewed for antibiotics therapy in sample of 19. The findings include: 1.R10 (Physician Order Sheet) showed Bactrim DS (antibiotic) 800-160 milligrams daily in the evening by mouth for ten days. No reason for antibiotic therapy (ABT) was entered either in the Physician Order sheet or in the medication administration log. R10 did not have a McGeer's criteria form in the infection control binder or his medical record for April . Further, the infection control and antimicrobial log did not have the reason for the medication administration. 2. R12's Physician Order Sheet dated 4/20/2024 showed Bacitracin (antibiotic) 2 percent ointment to apply to Gastrostomy tube redness and drainage two times daily until healed. The sheet dated 04/29/2024 showed Keflex 500 milligram four times tablet by mouth for ten days left lower extremity cellulitis. The April monthly…
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 · D2024-05-31 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to give residents appropriate written notices that their Medicare Coverage was coming to an end. This applies to 2 of 2 residents (R36, R41) reviewed for Medicare coverage in a sample of 19. The finding include: On 5/28/24 at 9:45 AM, entrance conference was completed with V1 (Administrator). Surveyor gave V1 the form titled Beneficiary Notice-Residents discharged Within the Last Six Months. Surveyor asked V1 to fill out the sheet with the names of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months. On 5/29/24 at 1:00 PM, V1 returned the form back to surveyor with only two resident's names (R36 and R41) on the form. V1 stated that V18 (Business Office Manager) completed the form. On 5/29/24 at 1:46 PM, V18 (Business Office Manager) stated, I started on 4/22/24. I'm new. I don't have a list of residents who were given a NOMNC (Notice of Medicare Non-Coverage) form and SNF-ABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) in the last 6…
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 · D2024-05-31 · 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 provide privacy during pressure ulcer dressing changes. This applies to 2 of 2 residents (R47, R50) reviewed for privacy in a sample of 19. The findings include: 1. R47's care plans show he has a gtube and stage 3 pressure ulcer to his right heel. V4's (Wound Doctor) note dated 5/22/24 shows that R47 has a stage 3 pressure wound to the right heel. Primary dressing: Alginate rope with silver. Apply once daily for 23 days. Secondary dressing: Foam silicone border. Apply once daily for 23 days. On 5/29/24 at 12:25 PM, V3 (RN-Registered Nurse) put on gloves and entered R47's room without wearing a gown. V3 removed R47's dressing on his right foot. V4 (Wound Doctor) put on gloves and came inside without wearing a gown. V4 measured (R41's) pressure sore wound on his foot. V3 then completed the dressing change on R47's foot as per the physician's orders. During the procedure, the door was left open and the curtain was only pulled halfway. R47's roommate was present in the room as well. 2. R50's face sheet shows 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 · Dcited before2024-05-31 · 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 the necessary services to maintain good personal hygiene for 1 of 11 residents (R11) reviewed for activities of daily living in the sample of 19. The findings include: On 5/28/24 at 9:39 AM, observed R11 lying in bed. R11's mouth was crusty and lips dry. R11 had very strong foul odor. On 5/28/24 at 2:30 PM, V5 (RN-Registered Nurse) stated, the foul odor on R11 is from his mouth and that it is because of some periodontal issue that R11 had. On 5/30/24 at 12:05 PM, V10 (CNA- Certified Nursing Assistant) stated, Mouth care is provided to prevent odor or to clear bad smell. Also to prevent any infection in the gums. V10 (CNA) stated, R11 had a strong mouth odor. V10 stated, sometimes, (R11) resists care and does not open his mouth and at other times he does. V10 stated, he had informed nurses multiple times in the past that R11's mouth smells bad. On 5/29/24 at 12:11 PM, V2 (DON-Director of Nursing) stated, she is not aware of any periodontal condition that R11 has. V2 stated, R11's mouth had very foul…
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 before2024-05-31 · 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 safely transfer a resident (R10) and safely position a resident (R14) when assisting with feeding in bed. This applies to 2 of 2 residents (R10 and R14) reviewed for accidents in a sample of 19. The findings include: 1. R10's Medical Record (MR) showed multiple diagnoses including general convulsant epilepsy intractable seizure disorder, left hemiparesis secondary to encephalitis, left homonymous hemiopia, and degenerative joint disease with arthritis. R10's MDS (Minimum Data Set) dated 4/07/2024 showed R10 required substantial to maximal staff assistance with transfers. On 5/28/2024 at 9:53 AM, R10 was sitting on the edge of her bed leaning on her left side, and was barefoot. V11 (Certified Nurse Assistance/CNA) said R10 was scheduled for a shower, and V11 proceeded to transfer R10 from the bed to the shower chair. V11 pulled and lifted R10 from her armpits when transferring into the shower chair, V11 did not use a gait belt. On 5/29/2024…
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 · D2024-05-31 · 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 monitor and ensure that a resident with orders for a double protein diet received the diet as ordered by the physician. The facility failed to ensure weight interventions were followed per policy. This failure resulted in a -10.16 % weight loss from November 2023 to May 2024. This applies to 1 of 1 resident (R40) who was reviewed for double protein diet in a sample of 19 residents. The findings include: On 05/29/2024 at 12:24 PM, R40 was in the dining room, not interviewable, and appeared emaciated and weak. At 12:15 PM, staff served R40 a meal tray. R40's meal card showed diet pureed, honey thick, double protein. R40's meal tray was served with regular portions of pureed meat, green beans, and smashed potatoes. R40's face sheet showed R40 is a [AGE] year-old female with diagnoses including type 2 diabetes mellites, iron deficiency anemia, chronic kidney disease, cerebral vascular accident, and dysphagia. R40's medical records did 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 · D2024-05-31 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure they had supply of gastrostomy tube feeding formula for residents per order, failed to label and date gastrostomy tube feedings and failed to follow physician's orders for feedings. This applies to 3 of 3 residents (R11, R12, R47) reviewed for gastrostomy tubes in a sample of 19. The findings include: 1. R12's face sheet shows diagnoses of quadriplegia, gastrostomy (g-tube) status, and dysphagia. R12's May POS (Physician Order Sheet) shows an order for Isosource HN (high nitrogen) at 80 ML/HR (milliliters/hour) per g-tube x 20 hours (may substitute with Jevity 1.5 if n/a): On at 9:00 AM and off at 5:00 PM. R12's care plan shows he receives enteral nutrition support. He has diagnosis of TBI (Traumatic Brain Injury) from motor vehicle accident. Current feeding Isosource 1.5 at 70 ML/HR x 20 hours with flushing water 325 ML every 6 hours (may substitute jevity 1.5 if Isosource is not available). On 5/28/24 at 10:41 AM, R12 was in bed. R12 is non-verbal. He was connected to a g-tube machine which 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 · Dcited before2024-05-31 · 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
Based on observation, interview and record review, the facility failed to store narcotic medications under double-lock and failed to properly store an inhaler. This applies to 2 out of 7 residents (R2 and R32) reviewed for medication storage in a sample of 19. The findings include: 1. On 5/29/2024 at 9:41 AM, facility's medication room was inspected with V5 (RN-Registered Nurse). It was observed that the medication refrigerator had no lock. Inspection of the refrigerator showed R2's opened Lorazepam Concentrate 2mg (milligrams)/ml (milliliter). The medication was opened on 3/19/2024. R2's May 2024 POS (Physician Order Sheet) shows order for Lorazepam Oral Solution 2 mg/ml, take 0.25 ml - 0.5 ml orally or sublingually every two hours as needed for agitation or restlessness. On 5/29/2024 at 9:41 AM, V5 said the refrigerator is never locked. On 5/30/2024 at 11:37 AM, V5 said all narcotics should be double locked to prevent theft and diversion of medication. She confirmed that R2's Lorazepam was in the unlocked refrigerator in the medication room. She again said that the refrigerator in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-31 · tag F0813 — isolatedHave a policy regarding use and storage of foods brought to residents by family and other visitors.
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 store resident food that requires refrigeration in the refrigerator, remove expired food, place a thermometer in the fridge, and complete temperature logs. This applies to 2 of 2 residents (R28, R51) reviewed for refrigerators in sample of 19. The findings include: 1. On 5/28/24 at 10:23 AM, during initial tour, surveyor went to R51's room. R51 was in the bathroom. On top of his dresser, he had the following opened items. Smooth ranch dip, two jars of 12 fluid oz (ounces) Miracle Whip, 1 bottle of 14 fluid oz of yellow mustard, 1 jar of 16 oz of extra hot giardiniera. On the items, it says refrigerate after opening. R51 did not have a refrigerator in his room. There was a package of ½ loaf of Brioche bread with a best by date of 4/26/24. On 5/30/24 at 10:05 AM, surveyor went back to R51's room to talk to R51. However, R51 was sleeping and surveyor could not interview him. The items were still on top of his dresser. 2. On 5/28/23 at 11:14 AM, surveyor went to R28's room. R28 had a fridge in his room. Inside…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-25 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 a full time DON ( Director of Nursing). This applies to all 57 residents residing in the facility. The findings include: The Facility Data Sheet dated April 17, 2024, showed the facility census was 57 residents. The area on the Facility Data Sheet designated for the DON (Director of Nursing) information was left blank. No DON was shown on the Facility Data Sheet. The area on the Facility Data Sheet designated for the ADON (Assistant Director of Nursing) was left blank. No ADON was shown on the Facility Data Sheet. On April 17, April 18, April 22, and April 23, 2024, there was no DON at the facility. On April 17, 2024, at 9:39 AM, V2 (Interim Business Office Manager) said the facility does not have a DON at this time. On April 18, 2024, at 9:24 AM, V1 (Administrator) said the facility does not have a DON. V1 continued to say the facility last had a DON on April 3, 2024. V1 said the facility does not have an interim DON. On April 18, 2024, at 10:23 AM, V1 said the facility does not have a waiver from IDPH…
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 before2024-04-25 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to employ a licensed administrator to ensure the facility could meet resident needs. The facility administration failed to ensure therapy services were provided to residents. The facility employed a full-time DON, and the administrator failed to ensure the facility employed a part-time Infection Preventionist. The administration also failed to document evidence for plans of correction and evidence of reporting to the QAPI (Quality Assurance Performance Improvement). This applies to all 57 residents residing in the facility. The findings include: The Facility Data Sheet dated April 17, 2024, showed the facility census was 57 residents. The area on the Facility Data Sheet designated for the Administrator's license number was left blank. On April 18, 2024, at 9:24 AM, V1 (Administrator) said she has a temporary nursing home administrator license. On April 18, 2024, at 10:23 AM, V1 said she started working at a different facility and came to work at this facility on March 4, 2024. V1 continued to say her temporary administrator…
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 · F2024-04-25 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to have an Infection Preventionist at least part time at the facility. This applies to all 57 residents residing in the facility. The findings include: The Facility Data Sheet dated April 17, 2024, showed the facility census was 57 residents. On April 18, 2024, at 2:17 PM, V9 (Regional Director of Clinical Operations) said she is the IP (Infection Preventionist) nurse until the facility hires a DON (Director of Nursing). V9 said she lives about three hours from the facility. V9 continued to say she tries to come to the facility once a week, but due to health issues V9 has had difficulty coming to the facility once a week. V9 said when she is able to come to the facility, V9 reviews and updates the infection control logs. V9 continued to say the March 2024 log was incomplete. The Facility Assessment Tool dated March 7, 2024, showed .The facility follows the current CDC (Centers for Disease Control and Prevention) best practices. The facility has an Infections Nurse that oversees the program in its entirety .
- Potential for harm · Fcited before2024-03-06 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 interview and record review, the facility failed to safeguard resident's individual narcotic medications and failed to secure the facility's emergency control medication box, which resulted in the disappearance of these medications. This applies to 2 of 2 residents (R1, R2) for missing individual prescriptions and has the potential to affect the remaining 55 residents in the facility reviewed for prescription medications. The findings include: On 3/5/24 at 9:15 AM, V1 (Administrator) submitted to surveyor the facility resident roster which shows there is a current census of 57 residents. On 3/5/24 at 9:16 AM, V1 stated she just started yesterday and was unaware of any incidents regarding the missing emergency medication box with controlled substances. On 3/5/24 at 9:22 AM, V2 (DON-Director of Nursing) stated, On 2/9/24, (V10-LPN) was working the night shift and she received a delivery of (R1) and (R2's) Norco. It was around 2 AM. On 2/10/24 in the morning, (V6) came and relieved (V10). They both did 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 · D2024-03-06 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 that controlled medications were not misappropriated. This applies to 2 of 2 residents (R1, R2) for missing Norco medications. The findings include: On 3/5/24 at 9:15 AM, V1 (Administrator) submitted to surveyor the facility resident roster which shows there is a current census of 57 residents. On 3/5/24 at 9:16 AM, V1 stated she just started yesterday and was unaware of any incidents regarding the missing emergency medication box with controlled substances. On 3/5/24 at 9:22 AM, V2 (DON-Director of Nursing) stated, On 2/9/24, (V10 - LPN/Licensed Practical Nurse) was working the night shift and she received a delivery of (R1) and (R2's) Norco. It was around 2 AM. On 2/10/24 in the morning, (V6 - RN/Registered Nurse) came and relieved (V10). They both did the count together. (R1) and (R2's) medications were there. Then, in the evening shift, (V7 - LPN) started her shift and counted the narcotics with (V6) who was the off going. Again, (R1) and (R2's) medications were there. I heard from (V10) that (V7) called her at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-06 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to complete an incident report and notify the state agency about theft of resident property. This applies to 2 of 2 residents (R1, R2) reviewed for narcotic medications in a sample of 2. The finding include: On 3/5/24 at 10:02 AM, V6 (RN-Registered Nurse) stated, A couple of weeks on 2/9 or 2/10, we were missing (R1) and (R2's) narcotic medications. We also were missing their pink sheets which has the name of the medications. I believe (V7-LPN/Licensed Practical Nurse) took them because I started to notice a trend or pattern in resident's medication missing. It was my process of deduction. I just didn't trust (V7) because she would want to leave early on her shift before the night nurse would come, so she could avoid counting the narcotics. On 3/5/24 at 10:15 AM, V2 (DON-Director of Nursing) stated, On 2/9/24, (V10-LPN) was working the night shift and she received a delivery of (R1) and (R2's) Norco. It was around 2 AM. On 2/10/24 in the morning, (V6) came and relieved (V10). They both did the count together. (R1) and (R2'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.
- Potential for harm · D2024-02-25 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 the facility's abuse policy and report and investigate an allegation of abuse. This applies to one of three residents (R1) reviewed for physical abuse. The findings include: The facility's abuse policy dated 10/14/2016 showed This facility affirms the right of our residents to be free from abuse This facility therefore prohibits mistreatment, neglect, or abuse of its residents and has attempted to establish a resident sensitive and resident secured environment. The purpose of this policy is to ASSURE that the facility is doing all that is within control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: .Identifying occurrences and patterns of potential mistreatment, neglect, abuse of resident .immediately protecting residents involved in identified reports of possible abuse; Implementing systems to investigate all reports and allegations of abuse . promptly and aggressively 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 · Ecited before2024-02-14 · tag F0880 — failed to prevent and control infections — patternProvide 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 apply the correct PPE (Personal Protective Equipment) prior to entering resident rooms who were COVID-19 positive. The facility also failed to post contact isolation and droplet isolation signage outside the rooms of residents who were COVID-19 positive. This applies to 7 of 7 residents (R1, R2, R3, R4, R5, R6, R7) reviewed for COVID-19 infection control. The findings include: On February 13, 2024 at 09:49 AM, V5 (Housekeeper) entered R1 and R2's room wearing a surgical face mask and gloves. R1 and R2's room was under COVID-19 isolation. The signage outside the room showed a gown, gloves, N95, and face shield should be worn prior to entering COVID-19 isolation rooms. V5 finished cleaning the room and exited at 09:55 AM. V5 washed her hands and went to the next room wearing the same surgical face mask. At 10:45 AM, V5 said for residents under COVID-19 isolation, they should wear a gown, N95 face mask, and gloves. On February 13, 2024 at 11:51 AM, V6 (CNA/Certified Nurse Assistant) entered R3 and R4's room…
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 before2024-02-01 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
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 employ a qualified, competent administration to manage the facility during an emergency and implement the emergency plan for loss of water services. This applies to all 60 residents residing in the facility. The findings include: Facility census, dated 1/23/24, showed there were 60 residents residing in the facility. On 1/30/24 at 9:26 AM, V1(Acting Administrator) stated he applied for a temporary nursing home administrators license but had not received his temporary license yet. V1 stated he sent his application for the license three months ago and began working as the facility temporary administrator three months ago. Long Term Care Facility Administrator Form, dated 11/16/23, shows V1 applied to begin as administrator at South [NAME] Rehab and Healthcare and attached a copy of the application for IL licensed administrator. Application for Licensure and/or Examination, dated 9/8/23, shows V1 applied for a temporary certificate…
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 before2024-02-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to to document assessment of wounds, treatments, and physician orders. This applies to 1 of 3 residents (R1) reviewed for wounds in a sample of 61. The findings include: Face sheet, undated, shows R1 was admitted to the facility on [DATE] and his admission diagnoses included stage 4 pressure ulcer of the sacral region, osteomyelitis of vertebra, sacral, and sacrococcygeal region, and hemiplegia following a cerebral infarction affecting his right dominate side. R1 was discharged from the facility June 1, 2022 when the family (V22) called 911 after a disagreement with the facility. Review of R1's clinical record showed R1 was transferred to the hospital emergency room on 2/25/22, treated for osteomyelitis of the sacral pressure ulcer, bacteremia, urinary tract infection, and acute and chronic kidney disease. R1 was readmitted to the facility on [DATE]. Nursing admission Assessment, dated 3/3/22, shows R1 was assessed to have a stage 4 pressure ulcer 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 · E2023-09-20 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
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 were seen by their attending physician as shown in the facility's policy. This applies to 11 of 12 residents (R2-R12) reviewed for physician services in the sample of 11. The findings include: On September 18, 2023, the facility provided a list of all residents and the primary care physician responsible for the resident's care at the facility. The facility identified R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, and R12 as residents under the care of V6 (Attending Physician). The facility does not have documentation to show the residents (R2-R12) have been seen by V6 (Attending Physician) since their admission to the facility. On September 19, 2023 at 8:24 AM, V2 (DON-Director of Nursing) provided admission dates for the following residents: R2 - January 24, 2023 R3 - April 17, 2023 R4 - March 22, 2023 R5 - May 4, 2023 R6 - January 30, 2023 R7 - June 8, 2023 R8 - December 29, 2022 R9 - April 10, 2023 R10 - January 25, 2023 R11 - October 28, 2022 R12 - December 26, 2022 On September 18, 2023 at 11:28 AM, V5…
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 · D2023-06-08 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 allow two consenting adults the right to cohabitate. This applies to 2 of 2 residents (R32 & R40) reviewed for roommates in the sample of 18. The findings include: R40's Face Sheet showed she is a [AGE] year old female with an original admission date of 4/21/21. The face sheet showed she has a history of brain cancer, seizures, and falling. R40's 5/9/23 Minimum Data (MDS) Set showed she was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. The MDS showed she required supervision and setup assistance for bed mobility; transfers; mobility on and off the unit; and eating. R40's 2/1/23 Bimonthly Psychiatric care showed, she is stable from a psychiatric standpoint . R40's 5/11/23 Social Service Note showed resident is alert and oriented .resident wants to share a room with a male resident. Both Residents are able to make decisions . R32's Face Sheet showed he is [AGE] year old male with an original admission…
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 · D2023-06-08 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 did not have a seat belt restraint unless medically necessary. The facility failed to have an order, consent, assessment, and care plan for a seat belt restraint for 1 of 1 residents (R19) reviewed for restraints in the sample of 18. The findings include: On 6/6/23 at 11:20 AM, R19 was sitting in a wheelchair in his room with a seat belt on. R19's left hand was contracted and he stated he was not able to remove the seat belt. R19 stated the seat belt was put on so he wouldn't fall out of his chair. On 6/6/23 at 11:58 AM, R19 propelled his wheelchair to the dining room table. At 12:00 PM, V5 CNA (Certified Nursing Assistant) sat down next to R19 and started to feed him his sandwich from his tray. R19's seat belt was not released during his supervised lunch. At 12:07 PM, V5 continued to feed R19 with the seat belt intact. On 6/7/23 at 2:55 PM, V2 DON (Director of Nursing) stated R19 was a chair bound resident that required assistance with activities of daily living and was in a restorative…
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 before2023-06-08 · 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 a resident received clean clothing daily for 1 of 2 residents (R34) reviewed for activities of daily living in the sample of 18. The findings include: R34's face sheet printed on 6/8/23 showed diagnoses including but not limited to history of transient ischemic attack, muscle weakness, and left sided hemiplegia (paralysis). R34's facility assessment dated [DATE] showed moderate cognitive impairment and staff assistance needed for bed mobility, transfers, walking, dressing, toilet use, and personal hygiene. On 6/6/23 at 11:50 AM, R34 was lying in bed and dressed in a black, cartoon character tee shirt. R34 was covered with a light sheet up to his waist. R34 stated he had not had his clothing changed or been out of bed all morning. R34 pulled back the sheet and was wearing black sweatpants with a navy-blue stripe down the side. A white, incontinence brief was visible sticking out of the waist band and a package of incontinence briefs…
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 · D2023-06-08 · 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 relieving interventions were in place for a resident at high risk for pressure ulcers for one of six residents (R53) reviewed for pressure in the sample of 18. The findings include: R53's face sheet printed on 6/8/23 showed diagnoses including but not limited to pulmonary embolism, atrial fibrillation, anemia, bipolar disorder, and depression. R53's facility assessment dated [DATE] showed cognitively intact and requires staff assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. R53's facility assessment incorrectly showed no incontinence issues. R53's pressure ulcer risk assessment dated [DATE] showed a high risk. R53's June 2023 physician orders showed: Prevalom boots (heel protectors) on while in bed. Turn and reposition per facility protocol. On 6/6/23 at 10:14 AM, R53 was lying on his back in bed with his head elevated. R53's feet were resting directly on the mattress.…
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 · D2023-06-08 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure splints were applied for residents with contractures, restorative programs were implemented, reviewed, and revised as needed for 2 of 3 residents (R15 & R19) reviewed for contractures in the sample of 18. The findings include: 1. On 6/7/23 at 8:50 AM, R15 was laying on his back in his bed. R15's left hand and fingers on his left hand were contracted. R15 did not have a splint on his left hand. No hand splint was visible in his room. R15 stated that no one does any ROM (range of motion) to his left hand so he tries to do what he can himself. R15 stated he gets pain to his left hand. R15 stated he used to have a splint for his left hand but it disappeared a long time ago. R15 stated he would wear the splint if he still had it. contracted left hand and fingers. On 6/7/23 at 9:03 AM, V9 CNA (Certified Nursing Assistant) came into R15's room and stated she has only been at the facility a week and has never seen a splint for R15's hand and has never put one on him. V9 stated she doesn't do any ROM to R15'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.
- Potential for harm · Dcited before2023-06-08 · 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 provide a safe transfer for 1 of 2 residents (R159) reviewed for safety in the sample of 18. The findings include: On 6/6/23 at 12:19 PM, R159 was leaning to the side in his padded reclining wheelchair. V9 CNA (Certified Nursing Assistant) was in his room and stated she could just transfer R159 to bed; a mechanical lift was not needed. At 12:21 PM, V11 CNA came into R159's room to help V9 transfer R159 to bed. V9 put the gait belt around R159. V11 had his arm under R159's arm pit and V9 was holding onto the gait belt. They tried to stand R159 up and V11 grabbed the back of R159's pants to stand while V11 grabbed the side of the residents pants. R159 couldn't bear weight with his transfer. V9 stated R159 was not able to bear weight. On 6/8/23 at 11:39 AM, V2 DON (Director of Nursing) stated a resident's transfer ability is based on V13's RN (Registered Nurse/MDS Care Plan Coordinator) assessment. V2 stated she thought R159 was a mechanical lift transfer. V13 stated R159's care plan stated he could be transferred…
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 before2023-06-08 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess a resident for therapy services to upgrade their diet for 1 of 1 (R38) reviewed for specialized rehabilitation services in the sample of 18. The findings include: R38's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include alcohol dependence, dementia without behavioral disturbance, essential hypertension, insomnia, and weakness. On 6/06/23 at 12:05 PM, R38 was in his room feeding himself a pureed diet. R38's facility assessment dated [DATE] showed he is severely cognitive impaired and has no symptoms of a swallowing disorder. R38's last nutritional assessment dated [DATE] completed by the facility's Registered Dietitian showed, . Pureed, Nectar thick liquids . Diagnosis: Liver cirrhosis, hypertension, dementia, Alzheimer's disease, insomnia, depression, right leg swelling, and psychotic disorder . Annual Assessment: Resident receiving pureed/NTL (nectar thick liquids) . No concerns with chewing 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.
- Potential for harm · Dcited before2023-06-08 · 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 prevent cross contamination of resident contact surfaces by not removing gloves after incontinence care and a dressing change prior to touching anything else for 2 of 2 residents (R54 & R15) reviewed for infection control in the sample of 18. The findings include: 1. On 6/7/23 at 1:12 PM, V12 RN (Registered Nurse/Wound Care Nurse) was in R15's room for a dressing change to a wound on his left outer ankle. V12 had gloves on and stated she was going to clean the peri wound, then the wound because the periwound was cleaner. V12 took saline and gauze and wiped the peri wound. V12 cleaned the red wound bed on R15's ankle with saline and gauze. V12 did not remove her gloves, picked up the scissors and cut open the calcium alginate package. V12 removed the calcium alginate and cut it to the size of the wound and applied it to the wound. V12 applied a border foam dressing on top of the wound and stated it was for protection and drainage. V12…
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
$231,656 in federal fines across 2 penalties. 2 Medicare payment denials on record.
- $83,335 — penalty dated 2025-07-08
- $148,321 — penalty dated 2024-02-01
- Medicare payment denial — starting 2025-08-06 for 36 days
- Medicare payment denial — starting 2024-03-01 for 152 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 LINEAGE HEALTHCARE — 5 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 | 2 of 5 | 1.6 | +0.4 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 1.8 | +1.2 vs chain |
| Quality measures | 2 of 5 | 3.2 | -1.2 vs chain |
The other 4 homes this chain runs (chain average 1.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| PARKWAY BANK AND TRUST COMPANY | Organization | 5% OR GREATER SECURITY INTEREST | since 12/01/2024 |
| BRAUNSTEIN, EPHRAIM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| DIENA, AHARON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| PETLIN HOLDINGS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2024 |
| CLAUSSEN, MARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| KLEIN, TOM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| MAHER, JAYNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
CMS files one row per role, so the 14 rows in the source record cover these 7 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.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 86% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $760K 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.
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 145825. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-14, 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.