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Aperion Care Westchester

2901 South Wolf Road, Westchester, IL 60154 · For profit - Corporation · 120 certified beds · (708) 531-1441 Medicare & Medicaid certified

Call the home — (708) 531-1441 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 20244 actual-harm citations$53,141 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 4 actual-harm citations
  • a high number of inspection citations overall (36) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $53,141 in federal fines (most recent 2024-06-28)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)
  • about 21% of its spending goes to commonly-owned related companies

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3005 Wolf Rd · (708) 575-0060 · Call to confirm hours
Pharmacy
3020 Wolf Rd · (708) 562-4033 · Call to confirm hours
Grocery
Mariano's0.2 mi
3020 Wolf Rd · (708) 562-4033 · Call to confirm hours
Park
Enterprise Dr &, Ashley Woods Dr · Typically dawn to dusk
Place of worship

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 4 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased3.3%13.4%15.4%better
Long-stay residents who lose too much weight6.3%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms97.3%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%3.1%3.3%better
Long-stay residents whose ability to walk worsened5.4%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.5%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine72.5%91.8%95.3%worse
Long-stay residents with pressure ulcers4.0%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control15.3%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table28.4%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine19.6%63.1%79.4%worse
Short-stay residents rehospitalized after admission26.6%26.1%22.6%worse
Short-stay residents with an outpatient ER visit10.4%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.952.021.67worse
Long-stay outpatient ER visits per 1,000 resident days1.852.221.80typical

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.

36.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.4%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
29.6%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 29.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.22 therapist hours per resident per day in 2026Q1 — more than 27% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.4%CMS range 22.2–51.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 6.3–15.710.7%Oct 2022–Sep 2024no 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 discharge29.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge18.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge22.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified90.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened6.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.5%CMS range 3.3–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS 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

0.65
RN hours/ resident / day
0.37
LPN hours/ resident / day
1.90
Aide hours/ resident / day
2.93
Total nurse hours/ resident / day
0.52
RN hoursweekends
38.2%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 115.2 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. 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 2.93 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 2.65 hrs/resident/day on weekends vs 3.04 on weekdays — 13% thinner on weekends. RN hours go from 0.70 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.

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

Inspection trend

16
deficiencies at the latest standard inspection (2025-07-25)
4
at the previous standard inspection (2024-08-28)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Actual harm · Gcited before2024-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop an effective plan to prevent and/or reduce the risk of falling for a resident identified to at high risk for falls, and failed to follow their fall prevention protocol to complete fall risk assessments quarterly and accurately assess and document fall risk factors. This affected 6 of 6 residents (R1, R2, R4, R5, R6 and R7) reviewed for falls and fall risk assessments. This failure resulted in R1 having multiple falls R1 had a fall in his room on 8/27/24 at 7:45AM, and then another fall same day at 1:47PM in the dining room that resulted laceration in left side eye brow forehead requiring sutures on 8/27/24 and third fall on 9/12/24 in the dining room that resulted in left eyebrow laceration re-opening. Findings Include: R1 is [AGE] year old resident and still currently in the facility. BIMs score of 2 (severe cognitive impairment). Fall risk assessment dated [DATE] scored 13, and on 9/13/24 scored 14. On 10/24/24 at 9:30AM, V12 (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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-06-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to perform pressure ulcer dressing changes as ordered by the physician for 2 of 3 residents (R1 and R2) reviewed for pressure ulcers in the sample of 9. This failure resulted in R1 developing an infected right heel pressure wound. The findings include: 1. R1's Wound Assessment Report dated 2/4/24 shows that she admitted to the facility with an unstageable pressure ulcer on her right heel measuring 5.5 cm (centimeters) x 6.8 cm x 0.1 cm with light serosanguineous (pink thin fluid secreted from wounds in the healing process) drainage present. R1's Wound Physician note dated 4/17/24 shows that R1's right heel pressure ulcer was now a stage 4 pressure ulcer measuring 8.5 cm x 5 cm x 1.9 cm. R1's right heel pressure ulcer had heavy purulent (thick pus like drainage from an infection) drainage and the wound progress was not at goal. That same report shows that Metronidazole (antibiotic) 250 mg crushed and sprinkled on wound daily for odor was ordered on 4/3/24 for 30 days. R1's Right Heel Wound Culture Report collected…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-12-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to protect a confused and vulnerable resident (R1) from being physically abused by a staff member and failed to follow their abuse policy by not preventing staff to resident physical abuse. This failure resulted in R1 obtaining facial injuries with noted scratches with active bleeding, swelling, pain and bruising that required the resident to be transferred emergently to a local hospital for further evaluation. Findings include: R1's face sheet indicated that resident admitted to the facility from an acute care hospital on [DATE] and has a past medical history not limited to: Alzheimer's Disease, Seizures, Vascular Dementia, Psychosis, Difficulty in Walking, Lack of Coordination, Weakness, Abnormalities of Gait and Mobility, Malignant Neoplasm of Brain, Atrial Flutter, Cerebral Infarction, and History of Falling. R1's Minimum Data Set Section C dated 11/13/2023 documented a score of BIMS (brief interview for mental status score) of 11…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-06-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately inform a physician of abnormal labs prior to a resident's change of condition of 4/03/2023 for one of thirty residents (R3) in the sample. This failure resulted in R3 having to be hospitalized due to acute hypoxemic respiratory failure, seizures, and hypernatremia. Findings Include: R3 is a [AGE] year old female who was originally admitted to the building on 7/26/2012 and still currently resides in the facility. R3 has multiple diagnoses including but not limited to the following: epilepsy, vitamin D deficiency, multiple sclerosis, severe protein calorie malnutrition, dementia, hypernatremia, hypokalemia, pressure inducted deep tissue damage, and gastrostomy. Facility lab report dated 4/3/23 shows in part but not limited to the following: blood urea nitrogen (BUN): 30 (High) and Sodium (Na): 157 mEq/L (Critically High). Facility progress note dated 4/5/23 states in part but not limited to the following: R3 was observed during rounds 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their abuse policy by not reporting an allegation of physical abuse to the Illinois Department of Public Health's Regional Office for one out of three residents reviewed for abuse in a total sample of nine. Findings Include: R4 is a [AGE] year old with the following diagnosis: spastic quadriplegic cerebral palsy, chronic kidney disease, heart failure, mild cognitive impairment, and contracture of the right hand and wrist. On 5/27/26 at 12:52PM, R4 was able to state name and birthdate correctly. R4 stated the date was 5/20/16 and R4 was in [NAME], IL. When asked if R4 has any issues or concerns in the facility, R4 stated no. When asked if R4 felt safe in the facility, R4 stated no. R4 reported a lady tried to drown R4 in the shower last week. R4 was unsure of the exact date and was unable to name the CNA. R4 described the CNA as a black female with long black hair. R4 reported the CNA sprayed R4 in the face with the water hose. R4 stated R4 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure that call lights were placed/secured within reach, failed to ensure that essential equipment was functioning, and failed to supervise an at risk for falls resident while outside smoking, This failure affects three of three residents (R1, R3, R4) reviewed for falls on the sample of four. Findings include:1.The (2/23/24-2/1/26) fall report affirms R1 fell on 3/18/24, 10/1/24, 12/8/24, 3/23/25, 8/12/25, 1/2/26, and 1/13/26 therefore seven (7) times within the last 24 months. R1's (3/18/24) fall occurrence note was requested, however was not received during the survey, on 3/5/26 at 1:40pm, V1 (Administrator) affirmed that the facility doesn't have it.R1's diagnoses include but not limited to dementia, bipolar disorder, end stage renal disease, dependence on renal dialysis, difficulty walking and unspecified fall. R1's (1/9/26) BIMS (Brief Interview Mental Status) determined a score of 7 (severe impairment). R1's (1/9/26) functional assessment affirms R1 requires substantial/maximal assistance with chair/bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0694 — isolated
    Provide 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

    Based on interviews and record review, the facility failed to follow policy procedures, failed to clarify physician orders, failed to ensure that the required rate for IV (Intravenous) infusion was ordered (prior to administration) and failed to document the rate of IV infusion for one of four residents (R2) reviewed for change in condition. Findings include:R2's care plan (revised 1/29/26) states the resident requires use of IV (Intravenous) fluids/medications related to hydration therapy. Interventions: Provide IV fluids as ordered. R2's (1/1/26) Physician Orders include Dextrose Intravenous Solution 5%. Use 2 liter intravenously one time only for dehydration for 2 days [infusion rate was excluded].R2's (January 2026) MAR (Medication Administration Record) includes Dextrose Intravenous Solution 5%. Use 2 liter intravenously one time only for dehydration for 2 days, which was documented as administered at 6:32pm, however the infusion rate was excluded.R2's (1/2/26) progress notes state, iv fluids d5 ns (normal saline) infusing and IV fluids continuous running however the infusion…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-24 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — 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 Medication Administration Policy by failing to administer medications in a timely manner. This applies to four of 15 residents (R2, R7, R4 and R5) reviewed for medication administration in a sample of 15.The Findings include:On 9/23/25 at 10:12 AM, V6 (Licensed Practical Nurse/LPN) was passing medication and stated, I have 10 more residents (R2, R3, R4, R7, R8, R9, R10, R11, R14, and R15) to pass the morning medications, which were supposed to be administered at 8:00 AM. We are supposed to administer medications within 2-hour window (one hour before and one hour after) around the scheduled time. I would be able to finish by 10:45 AM.R2 is an [AGE] year-old female with moderate cognitive impairment as per MDS dated [DATE]. On 9/24/25 at 12:30 PM, R2 stated (with Spanish interpreter V8/Housekeeping), I don't know what time I received my medications today. I would like to get my medications on time.A review of the R2's POS and MAR…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-07-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to wear gloves while touching food while taking food temperatures before lunch was served, failed to wear beard nets and properly wear hair nets while in the kitchen area. This failure has the potential to affect all residents receiving meals in this facility. Findings include:The census on 7/22/25 was 114 residents. V12 DON (director of nursing) stated that there are four residents that are strict nothing by mouth.On 7/22/25 at 9:55 AM, V14 (cook), V15 (dietary aide), and V16 (dietary aide) were observed to have facial hair. V14, V15, and V16 were not wearing beard nets. V15 and V16 were observed with a hair net on head with hair extending below the hair net.On 7/22/25 at 10:40 AM, this surveyor observed a bag of hair nets and a bag of beard nets attached to door to the kitchen. V13 (dietary supervisor) arrived at the kitchen and placed a hair net on head with hair extending below the hair net.On 7/22/25 at 11:00 AM, V14 was observed preparing the gravy for the lunch meal service. V13 was not wearing…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-07-25 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to have an effective pest control program and ensure the kitchen area was free from flying insects. This failure affects all residents that receive meals in this facility. Findings include:On 7/22/25 at 10:40 AM, this surveyor toured the facility's kitchen with V13 (dietary supervisor). In the pantry where canned goods are stored, there were several, too active to count, fruit flies present.On 7/22/25 at 10:50 AM, V13 stated that there is no food stored in the pantry. V13 stated they are just fruit flies. V13 stated that the outside pest control company came to facility yesterday and provided treatment in the kitchen.On 7/23/25 at 12:15 PM, V7 (maintenance director) stated that the outside pest control company are here today placing extra traps for fruit flies throughout facility, mostly in the kitchen. V7 stated that some fruit flies were observed under the dishwasher. V7 stated that V13 informed him yesterday afternoon of fruit flies in the kitchen.The outside pest control company's service inspection…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-25 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, this facility failed to follow its policies and procedure to ensure resident received incontinence care at least every two hours or as needed, and failed to ensure a resident was positioned per physician order for feeding. This affected four residents (R103, R48, R61, and R113) reviewed for activities of daily living assisted by staff on the sample of 45.Findings include:On 7/22/25 at 12:25 PM, R48 was observed in reclining chair in dining room; head was raised 30 degrees. R48 was brought lunch tray. R48 was not repositioned, the chair back was not raised to the upright position. R48 was observed coughing after each bite taken.On 7/23/25 at 8:50 AM, R48 was observed in bed with head of bed raised 30 degrees. R48's breakfast tray was positioned in front of R48. V10 CNA (certified nurse aide) was observed in R48's room. R48 asked V10 to have the head of bed raised so R48 could eat breakfast. V10 stated that R48 can raise the head of bed herself and exited…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-25 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the medication storage policy by having opened undated medication and expired medication of the medication cart. This affected four of four residents (R3, R74, R113 and R95) reviewed for labelling and storage in the sample of 45. Findings Include:R3 was diagnosis with Dementia Mellitus. R3's physician order dated [DATE] documents: Insulin lispro solution - Inject as per sliding scale (start date [DATE]). R74's physician order dated [DATE] documents: Brimonidine Tartrate Ophthalmic Solution 0.2 % (Brimonidine Tartrate) Instill 1 drop in right eye eve (start date [DATE])On [DATE] at 12:18pm, during medication cart inspection with V31 (nurse), R3 was observed with lispro insulin dispensed date [DATE] open and not dated. V31 said, R3's insulin was used, open and not dated. V31 said, R3's insulin should have been dated when it was initially opened. R74 was observed with Brimonidine eye drop dated [DATE]. V31 said, R74's eye drops are…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-25 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and records reviewed the facility failed to ensure staff wear gloves when handling soiled laundry and failed to follow the facility failed to follow its glucose testing policy by not placing a barrier between a used glucometer and the medication cart, and failed to perform hand hygiene and clean the glucometer while taking blood glucose levels. This affected two of two residents ( R7, R3) reviewed for infection control practices and residents residing on the 200 hall. Findings Include: The findings include: On 07/23/2025 at 11:00 AM V4, Laundry Aide, observed in the 200 hall removing laundry from 1st soiled bin. V4 wearing no gloves. V4 then pushed her laundry cart to a 2nd bin wearing no gloves and adjusted the bag inside, closed the bin and then went to 3rd laundry bin. V4 wore no gloves when removing or adjusting bags on the soiled laundry bins. At 11:04 AM V4 said they tell us not to wear gloves when collecting laundry in the hall way. On 07/23/2025 at 11:52 AM V6, Infection Preventionist, said gloves should be worn when handling gloves 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure residents were treated in a dignified manner by providing timely toileting assistance. This failure affected three residents (R48, R61, and R113) reviewed for resident rights on the sample of 45. Findings include:On 7/22/25 at 3:20 PM, R48 was observed sitting in the dining room. R48 stated that R48 was wet and staff won't change R48's brief. R48 stated that staff had not changed her brief since she got in reclining chair for breakfast.On 7/22/25 at 3:40 PM, V18 CNA (certified nurse aide) was observed providing incontinence care for R48. R48 was observed to have a saturated panty liner (13 inches x 28 inches) in a saturated brief.On 7/22/25 at 3:40 PM, V18 CNA stated that V18 provides incontinence care to assigned residents twice, once at the beginning of shift and once at end of shift.On 7/23/25 at 12:50 PM, R113's call light was observed to be activated. At 1:00 PM, when questioned if R113 needed staff assistance, R113 removed blanket and pointed to incontinence brief. When questioned if R113…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 22 citations
  • Potential for harm · D2025-07-25 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 interviews and record reviews, the facility failed to accurately incorporate a resident's directive for life sustaining treatment into the medical record. This failure affected one resident (R9) reviewed for advance directives in the sample of 45.Findings include:On [DATE] at 1:30 PM, V8 SSD (social services director) stated that R9 is a full code. This surveyor and V8 reviewed the completed POLST (practitioner order for life-sustaining treatment) form, dated [DATE], in R9's medical record, acknowledged that R9 has signed DNR (do not resuscitate) form. V8 stated that the R9's family revoked the DNR status. When questioned for documentation of revocation, stated it is in her progress notes. This surveyor reviewed V8's progress notes with her, V8 stated that there is no documentation that DNR was revoked. V8 stated that neither R9's care plan nor the face sheet were not updated to note change in R9's code status.R9's face sheet, care plan, and POS (physician order sheet) note R9 is a full code.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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interviews, the facility failed to provide privacy while providing a bed bath. This affected one resident (R48) reviewed for privacy while receiving direct care on the sample of 45. Findings include:On 7/23/25 at 9:35 AM, V11 CNA (certified nurse aide) and V6 ADON (assistant director of nursing) were observed entering R48's room. V11 closed the door behind them. R48's roommate was observed sitting in wheelchair facing R48's bed. V11 gathered supplies to provide R48 a bath. R48's privacy curtain was not closed around R48's bed. R48's right arm was removed from gown exposing right breast. At 9:41 AM, R48's left arm was removed from gown exposing both breasts and abdomen. At 9:44 AM, another staff member entered R48's room to speak with V6. Afterwards, V11 pulled the privacy curtain to finish bathing R48.On 7/25/25 at 9:50 AM, V6 ADON stated that the resident's door should be closed and privacy curtain pulled around resident's bed to provide privacy prior to providing resident care.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 — the official record, unedited, may be distressing

    Based on observation and interview the facility failed to ensure the resident room was clean and sanitary for one of 8 residents (R59) in total sample of 45 reviewed for clean homelike environment. Findings include:On 7/22/25 at 1:10pm R59 said the floor in his room is dirty and sticky. Surveyor shoes was sticking to the floor when taking steps.Facility policy titled housekeeping, no date noted denotes in-part to provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to have an appropriate diagnosis for the use of antipsychotic medications, failed to identify a specific behavior for the use of an antipsychotic medication. This failure affected two residents (R8 and R9) reviewed for unnecessary medications on the sample of 45.Findings include: 1.R9's medical record notes R9 with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 7/23/25 at 3:45 PM, V12 DON (director of nursing) provided this surveyor with signed psychotropic consents for gabapentin (for treatment of nerve pain) and mirtazapine (appetite stimulant). When questioned if this was all of R9's signed consents for psychotropic medications, V12 responded yes. On 7/24/25 at 11:50 AM, V6 ADON (assistant director of nursing) reviewed R9's current medication orders. V6 stated that R9 is receiving olanzapine for a psychotic disorder. V6…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-07-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and records reviewed the facility failed to follow orders and obtain a urine analysis ordered on 4/6/25 for a resident with a history of urinary tract infections This affected one resident (R22) reviewed for physician orders on the sample of 45.The findings include:R22 has impaired cognition and diagnosis include, but are not limited to Alzheimer's Disease, Major Depressive Disorder, and Dementia. R22's Functional Abilities dated 6/3/25 identifies dependent on staff for toileting hygiene and always incontinent of urine.On 07/22/2025 at 10:36 AM R22 sitting in a wheel chair in the dining room. R22 alert, confused not talking or verbally responding, just looks at the surveyor.On 07/22/2025 at 3:45PM V24, R22's daughter, said on 4/6/25 I came to visit my mother and she was rambling. V24 said when she does that, I know that is a sign she is developing a UTI. I notified the nurse. We asked what happened, was anything going on with her and telling them she is not herself. V24 said then on 4/24/25 my sister came to see mom and had her sent to the ER. V24 said at the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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 observations, interviews, and record reviews, the facility failed to ensure enteral feeding and tubing is properly labeled and dated before administration, failed to ensure tubing was in correct position in the feeding pump for one resident (R113) reviewed for enteral feedings on the sample of 45. Findings include:On 7/22/25 at 3:30 PM, R113 motioned for this surveyor to enter his room. When questioned what the matter was, R113 pointed to his gastrostomy feeding that was hanging on the intravenous pole next to his bed. R113's gastrostomy feeding tubing was observed not connected to the feeding pump and the clamps on the tubing were open. The feeding container was not labeled with R113's name or date and time hung.On 7/22/25 at 3:35 PM, V12 DON (director of nursing) came to R113's room. V12 stated that the feeding should not be running like that. V12 stated that the tubing should be connected to the pump. V12 stated that the day shift nurse didn't know how to connect the tubing to the feeding pump. When questioned what is the expectation for the nurses if they do not know…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 observations, interviews, and record reviews, the facility failed to ensure oxygen tubing changed and dated weekly. This failure affected two residents (21 and R48) reviewed for respiratory care on the sample of 45. Findings include:On 7/22/25 at 10:05 AM, R21 was observed in room with oxygen tubing placed behind R21. R21's oxygen tubing was undated.On 7/22/25 at 10:30 AM, R48 was observed in dining room. R48's oxygen tubing was dated 7/14/25. On 7/23/25 at 9:35 AM, R48's oxygen tubing was dated 7/23/25.On 7/25/25 at 9:50 AM, V6 ADON (assistant director of nursing) stated that oxygen tubing is changed weekly and as needed. V6 stated that the oxygen tubing should be dated when changed. V6 stated that the date noted on the oxygen tubing should match the date documented in the resident's MAR (medication administration record). R21's POS (physician order sheet), dated 9/18/22, notes an order to change out, date, and label oxygen tubing every night shift every Sunday.R48's POS, dated 3/27/24, notes an order to change out, date, and label oxygen humidifier 500ml (milliliters) and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to ensure the call light was functioning for a dependent resident R2 reviewed for functioning call light system in total sample of 45 residents.Findings include: R2 face sheet shows diagnosis of unspecified osteoarthritis, lack of coordination, need for assistance for personal care.On 7/22/25 at 2:37pm R2 said the call light for her bathroom shower is not working. R2 said the light should be working so that she can pull the string if she needs help from the staff. R2 did not give a situation/ time/ episode of an event that she pulled the shower call light and staff did not respond and she had to wait. R2 said she told maintenance about the call light last week.Surveyor pulled the cord to the call light for the shower (in R2 bathroom) , and the light did not illuminate at the call light box, or above the entry door to the room, the string did not pull.7/22/25 V30 (RN) was made aware immediately upon exit of R2 room that R2 call light for the shower is not working in R2's room.On 7/24/25 with assist from V7…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-07-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that resident care equipment was clean and in good, repaired condition and properly stored by not comingling with functional ones to prevent accidental use for prevention of infection. This failure has the potential to affect R1, R3, R4, R5 and R6 reviewed for infection control. Findings include: R1's medical record admission record showed documentation that R1 was last admitted to the facility on [DATE] and listed diagnosis includes but not limited to Spastic quadriplegic cerebral palsy, spondylolysis lumbar region, type 2 diabetes mellitus with other circulatory complications, unspecified symptoms and signs involving cognitive functions and awareness, contracture of muscle, contracture of right wrist, joint disorder, contracture of muscle right hand, and low back pain.On 07/03/25 at 9:45am, V3 stated that (R1) and (R3) uses the shower device but R1 family member (V13) left instruction not to use the device until the bed pad is changed. V3 stated…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to follow its abuse prevention policy and prevent an incident of resident to resident physical assault. This affected two of three residents (R2, R3) reviewed for physical abuse. This failure resulted in R2 attacking and hitting R3 with a cane unprovoked. Findings include: On 10/23/24 at 11:15AM, V3 LPN (licensed practical nurse) R2 ambulates with a cane. V3 stated that on 9/3/24, staff alerted her that R2's roommate, R3, stated R2 hit R3 with his cane. V3 stated that R2 was still agitated when she arrived at R2 and R3's room. V3 stated that R2 was non-redirectable; swearing at her and V10 CNA (certified nurse aide), raising cane, getting aggressive. V3 stated that in the past, R2 was re-directable when R2 exhibited behaviors. On 10/23/24 at 1:40PM, V10 CNA stated that R3 informed V10 that R2 hit him with R2's cane. V10 denied witnessing R2 hit R3. V10 stated that R2 became aggressive towards her and V3. V10 stated that usually V10 can re-direct R2 when behaviors exhibited. V10 stated that some days R2's behavior was okay…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-28 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 administer medications as ordered; failed to ensure medication is available during medication administration; and failed to follow manufacturer's guidelines in insulin pen administration. There were 27 opportunities with eight errors resulting in a 29.63% medication error rate. The errors involved four (R46, R63, R82 and R86) of 10 residents in the sample of 47 reviewed for medication administration. Findings include: R63 is a [AGE] year-old, female, admitted in the facility on 03/20/23 with diagnosis of Type 2 Diabetes Mellitus without Complications. POS (Physician Order Sheet) dated 08/16/24 recorded: Humalog Kwikpen Subcutaneous Solution Pen Injector 100 unit/ml (milliliter) Insulin Lispro inject 5 units subcutaneous with meals for diabetes. On 08/25/24 at 12:03 PM, V4 (Licensed Practical Nurse, LPN) was preparing the Humalog Kwikpen to R63. V4 took the Humalog Kwikpen from the cart, wiped the needle port with alcohol wipes, and pushed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-28 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their policy and procedures for infection control by not ensuring a catheter urinary drainage bag was protected from contaminated surfaces for a resident with a history of UTI's (Urinary Tract Infection); failed to date nasal cannulas and humidifier bottles for residents receiving oxygen; and failed to perform hand hygiene or wear personal protective equipment when providing care to residents on enhanced barrier precautions. This failure applied to five of five residents (R40, R46, R64, R86, and R296) reviewed for infection control. Findings include: R46 is a [AGE] year-old male with a diagnoses history of COPD, Emphysema, Dependence on Supplemental Oxygen, Gastrostomy Status, and Pancytopenia (Abnormally low levels of all blood cell types) who was admitted to the facility 10/22/2021. On 08/25/24 at 12:48 PM Observed R46 's oxygen tubing and humidifier bottle in use and not dated. R86 is a [AGE] year-old male with a diagnoses…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of abuse for one of two residents (R73) reviewed for abuse in a total sample of 47. Findings include: R73 is a [AGE] year-old resident admitted to facility on 11/22/2021 with medical diagnoses including but not limited to: vascular dementia, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R73 has a Brief interview mental status (BIMS) score of 03 dated 08/12/2024 which suggests severe cognitive impairment. Minimum Data Set (MDS) assessment dated [DATE] documents GG0130 Self - care: R73 is dependent for toileting hygiene, shower/bathe self, and putting on and taking off footwear. R73 requires substantial/maximal assistance with lower body dressing. R73 requires partial/moderate assistance with eating, oral hygiene, upper body dressing and personal hygiene. On 08/25/24 at 11:45 AM R73 - I have lived here 3 years. I don't like it here. R73 made the choking sign.…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures for Urinary Catheter Care by not ensuring a catheter urinary drainage bag was emptied timely for a resident with a history of UTI's (Urinary Tract Infections). This failure applies to one of one residents (R86) reviewed for catheters and UTI's (Urinary Tract Infections). Findings include: R86 is a [AGE] year-old male with a diagnoses history of UTI's Neuromuscular Bladder Dysfunction, Pseudomonas Bacteria as the Cause of Other Diseases, Acute and Chronic Congestive Heart Failure, Presence of Coronary Artery Graft (Transplanted Blood Vessels), and Pressure Ulcers who was admitted to the facility 03/30/2024. On 08/25/24 from 10:18 AM - 10:30 AM Observed R86's catheter (urinary drainage) bag extremely full. R86 stated if his catheter (urinary drainage) bag is full and it backs up, It could mess me up. R86 stated they constantly forget to empty his catheter (urinary drainage) bag. R86 informed the surveyor…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-25 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide sufficient nursing coverage on specific days and shifts ensuring adequate resident care and assistance for four (R6, R7, R10 and R11) of four residents reviewed for staffing. This deficiency also has the potential to affect all the 95 residents currently residing in the facility. Findings include: Per residents' census report dated 07/22/24, there are 95 residents currently residing in the facility. On 07/22/24 at 11:05 AM, R6 was observed in bed, alert, oriented with ongoing oxygen treatment at 3 liters per minute via nasal cannula. R6 stated during interview that her incontinence brief is not changed when soiled in a timely manner. R6 also verbalized a concern regarding staffing problem in the facility that she needs to wait to get changed. On 07/23/24 at 9:40 AM, incontinence care observation was conducted on R6 showing that her brief was fully soaked with urine, with moderate amount of soft bowel movement. Incontinence pad was also wet with urine. The flat sheet covering her mattress was wet with urine which…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-25 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to provide necessary incontinence care in a timely manner on residents who are dependent on staff for performing their activities of daily living. This deficiency affects four (R6, R7, R10 and R11) of four residents reviewed for activities of daily living. Findings include: R7's medical record documents R7 initially admitted in the facility on 12/09/20 with diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified; Parkinson's Disease without Dyskinesia, without mention of fluctuations; Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. MDS (Minimum Data Set) assessment dated [DATE] documented: Section GG - Toileting hygiene: partial/moderate assistance to maintain perineal hygiene. R7's care plan on bowel and bladder incontinence related to cognitive impairment dated 08/31/22 recorded - Intervention: Clean peri-area with each incontinence episode. On…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-28 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who needs extensive assistance with activities of daily living (ADLs) received incontinence care in a timely manner for 1 of 5 residents (R2) reviewed for ADLs in the sample of 7. The findings include: On 6/28/24 at 10:30 AM, V10 (Certified Nursing Assistant) provided incontinence care to R2. R2's room smelled of urine and R2's incontinence brief was saturated. V10 said that his shift started at 6:00 AM and he has not changed her yet that morning. V10 said that the last time she was provided incontinence care was sometime before his shift started (4.5 hours ago). On 6/28/24 at 12:26 PM, V2 (Director of Nursing) said that all incontinent residents should be change every two hours or sooner if needed. V2 said that 4 hours is too long. R2's Minimum Data Set assessment dated [DATE] shows that she is dependent on staff for toileting and is always incontinent of urine and stool. R2's Bowel and Bladder Incontinence Care Plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure wound dressing changes were performed as ordered by the physician for 2 of 3 residents (R1 and R6) reviewed for quality of care in the sample of 9. The findings include: 1. On 6/28/24 at 10:53 AM, V11 (Wound Care Registered Nurse) performed a dressing change on R6. V11 removed R6's dressing from his left lower leg. There was a large amount of bloody drainage on the two large absorbent pads that were covering the wound. R6's lower legs had multiple open areas present with bright red blood coming from them. On 6/28/24 at 10:53 AM, V11 said that R6's dressing is ordered to be changed every Monday, Wednesday and Friday. V11 said that the wound physician changes the dressing on Wednesdays and he changes the dressings on Monday and Fridays. V11 said that once he does the dressing change, he charts it on the Treatment Administration Record (TAR). R6's May TAR shows an order dated 4/26/24-5/8/24 for: Left Lateral Calf-collagen-cleanse area…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-03 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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

    Based on observation, interview and record review the facility failed to maintain resident rooms in a clean and sanitary manner for 4 residents R1, R2, R4, R6 reviewed for clean, comfortable, homelike environment in the sample of 21. The findings include: The Facility Data Sheet dated 5/3/24 showed a resident census of 104 residents. On 5/3/24 at 7:40 AM, R2 was seated in bed. A urinal, filled with 600 milliliters (mls) of urine, was on his beside table. No lid was noted on the urinal bottle. Directly next to the urinal, was a sandwich. R2 pointed at the sandwich next to the urinal, I won't eat that. That's terrible. Gross. R2's garbage container, on the floor next to his bed, was overflowing with garbage. On 5/3/24 at 8:00 AM, this surveyor walked down the 200 unit hallway with V3 Certified Nursing Assistant (CNA). This surveyor's shoes stuck to the floor walking down the hallway. V3 wore shoe coverings over her shoes. V3 stated she wore shoe coverings over shoes because I don't like my shoes sticking to the floor either. On 5/3/24 at 8:02 AM, R6 laid in bed. A urinal, half-filled…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-03 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to provide ADL (activities of daily living) assistance to residents that required staff assistance for toileting/incontinence care, nail care, and oral hygiene for 3 of 7 residents (R4, R3, R2) reviewed for activities of daily living in the sample of 21. The findings include: 1. R4's current care plan showed R4 required staff assistance with toileting and incontinence care related to his diagnosis of CVA (cerebrovascular accident) The care plan showed R4 was incontinent of urine and stool. The plan showed R4 also required staff assistance for nail care with a care plan intervention of check nail length and trim and clean on bath day and as needed. R4 was cognitively impaired due to his diagnosis of dementia. On 5/3/24 at 8:20 AM, R4 was asleep in bed. No sheet was noted on R4's bed. Stool was noted leaking out of R4's incontinence brief, directly onto R4's bare mattress. All of R4's fingernails had thick, black debris under his nails. On 5/3/24 at 8:33 AM, V3 Certified Nursing Assistant (CNA) entered R4's room to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-07-25 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview the facility failed to post Nurse Staffing Data in a prominent area available for residents and visitors. This failure has the potential to affect all residents residing in the facility. The findings include:07/22/2025 11:49 AM Staffing not posted at desk, V5, Receptionist, handed surveyor the schedule for review. Surveyor requested the information be provided. Surveyor checked in the area and no posting seen.07/22/2025 1:56 PM V3, Interim DON, said Human Resources, V2, created the Daily Nursing staff census today. V3 said I am unable to provide the Daily Nursing Staff Census for the past 30 days.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2025-07-25 · tag F0577 — pattern
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    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 that the state inspections are available for the residents to read without having to ask the staff for them. This affects 4 of 4 residents (R91, R40, R111, R23) in the sample of 45 resident reviewed for residents' rights for state inspection. Findings include: On 7/23/25 at 11:10am R98 (president of resident council) said the survey binder/ state inspections was at the front desk. R23 and R111said they don't know what the survey binder are with the state survey results.On 7/25/25 at 8:48am during tour, there was no survey binder observed out in view at the front desk. Request was made to review the survey binder with previous state inspections, V5 (receptionist) looked at the binders that was located in the back of the receptionist desk and stated that the binder is not there. V34 (Regional Nurse Consultant) said the survey binder should be at the front desk. V34 and V12 looked for the survey binder in the administrator's office, and around the front desk area, foyer near the smoke patio.7/25/25 8:57am…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$53,141 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $38,948 — penalty dated 2024-06-28
  • $14,193 — penalty dated 2023-12-03
  • Medicare payment denial — starting 2024-07-18 for 8 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 APERION CARE — 33 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 →

RatingThis homeChain avg
Overall 3 of 51.9+1.1 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 2 of 51.6+0.4 vs chain
Quality measures 2 of 53.3-1.3 vs chain
The other 32 homes this chain runs (chain average 1.9★, per CMS)
1 of 5Aperion Care Arbors Michigan CityMichigan City, IN 1 of 5Aperion Care DemotteDemotte, IN 1 of 5Aperion Care DoltonDolton, IL 1 of 5Aperion Care Forest ParkForest Park, IL 1 of 5Aperion Care HanoverHanover, IN 1 of 5Aperion Care InternationalChicago, IL 1 of 5Aperion Care KokomoKokomo, IN 1 of 5Aperion Care LakeshoreChicago, IL 1 of 5Aperion Care LincolnEvansville, IN 1 of 5Aperion Care MidlothianMidlothian, IL 1 of 5Aperion Care MonroeBloomington, IN 1 of 5Aperion Care Oak LawnOak Lawn, IL 1 of 5Aperion Care Tolleston ParkGary, IN 1 of 5Aperion Care VincennesVincennes, IN 1 of 5Aperion Care WesleyChicago, IL 1 of 5Aperion Care WilmingtonWilmington, IL 1 of 5Arcadia Care MortonMorton, IL 2 of 5Alta Rehab At FairmontChicago, IL 2 of 5Alta Rehab At Oak BrookOak Brook, IL 2 of 5Aperion Care Chicago HeightsChicago Heights, IL 2 of 5Aperion Care DekalbDekalb, IL 2 of 5Aperion Care GreenfieldGreenfield, IN 2 of 5Aperion Care Marion LLCMarion, IN 2 of 5Aperion Care PeruPeru, IN 2 of 5Aperion Care West ChicagoWest Chicago, IL 2 of 5Park Ridge Healthcare CenterPark Ridge, IL 3 of 5Aperion Care BurbankBurbank, IL 3 of 5Aperion Care ElginElgin, IL 5 of 5Alta Rehab At WaucondaWauconda, IL 5 of 5Aperion Care Fox RiverElgin, IL 5 of 5Aperion Care NilesNiles, IL 5 of 5Aperion Care SummerfieldCloverdale, IN

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 / managerTypeRoleShareSince
RIDGEVIEW INVESTOR GROUP LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF25%since 04/01/2021
JOSHUA HOFFMAN TRUSTOrganizationDIRECT OWNERSHIP INTERESTsince 04/01/2021
YTLM EQUITIES, LLCOrganizationDIRECT OWNERSHIP INTERESTsince 04/01/2021
GEIGEL, KATHERINEIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 04/01/2021
NWAKUDU, URSULAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
SPECTOR, JENNIFERIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
TUROFSKY, STEVENIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2023
ULBERT, LISAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
WILHELM, NAFTALIIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
APERION CARE INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
BARAJAS-MORAN, ILIANAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
HUSSAIN, JAWWADIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2021
BERKOWITZ, DAVIDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/16/2025
MEYSTEL, YOSEFIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/16/2025
2901 WOLF ROAD, LLCOrganizationADP OF THE SNFsince 03/31/2025
APERION CARE EXEC HOLDINGS LLCOrganizationADP OF THE SNFsince 04/01/2021
APERION CONSULTING, LLCOrganizationADP OF THE SNFsince 04/01/2021
CURIS SERVICES LLCOrganizationADP OF THE SNFsince 04/01/2021
DAVID A BERKOWITZ DELTA TRUSTOrganizationADP OF THE SNFsince 04/01/2021
DAVID A BERKOWITZ REVOC TR DAVID BERKOWITZ TTEEOrganizationADP OF THE SNFsince 04/01/2021
YOSEF MEYSTEL DECLARATION OF TR OF YOSEF MEYSTEL TTEEOrganizationADP OF THE SNFsince 04/01/2021
YOSEF MEYSTEL DELTA TRUSTOrganizationADP OF THE SNFsince 04/01/2021

CMS files one row per role, so the 37 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.

12 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.

$11.3M
Net patient revenuemost recent cost report
-10.2%
Operating marginrevenue minus expenses
$2.6M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 22%Medicare 6%Other / private 72%

This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$338per resident / day
operating cost
$10,265per month
≈ monthly operating cost
$307per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 145660. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-25, 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.

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