Burgess Square Healthcare Ctr

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

62.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 1,095 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 61.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 615 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 1.00 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 203 beds and averages 123.1 residents a day — about 61% occupied, or roughly 80 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.71 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.60 hrs/resident/day on weekends vs 5.08 on weekdays — 9% thinner on weekends. RN hours go from 1.82 to 1.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

• Actual harm · Gcited before2026-05-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor for and report changes in existing pressure ulcers, prevent the development of new pressure areas, and failed to ensure pressure ulcer treatments were in place.This failure resulted in delayed identification of a resident's stage two coccyx pressure ulcer deteriorating to a necrotic and unstageable pressure ulcer, with a subsequent delay in treatment changes.This applies to 2 out of 4 (R1and R4) reviewed for pressure ulcers. The findings include:1. The EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, dementia, muscle weakness, squamous cell carcinoma of skin, abnormalities of gait and mobility, and needs assistance with personal care. The MDS (Minimum Data Set), dated March 24, 2026, showed R4 was cognitively intact and dependent on staff for ADLs (activity of daily living). The MDS continued to show R4 was at risk for developing pressure ulcers…

  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 · G2025-11-20 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 administer blood thinner medication as ordered by the physician. This failure resulted in R1 experiencing an elevated INR (International Normalized Ratio) blood test and requiring the administration of Vitamin K and hospitalization. This applies to 2 of 3 residents (R1, R4) reviewed for medication administration in the sample of 5.The findings include: 1. On November 17, 2025, R1 was sitting quietly. She was unable to answer questions due to her cognitive status.The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. The EMR continues to show R1 was sent to the local hospital on November 4, 2025 and returned to the facility on November 5, 2025. R1 has multiple diagnoses including, kidney stones, bacteremia, sepsis aftercare, asthma, ureteral stent, tachycardia, anemia, difficulty walking, and long-term use of anticoagulants. R1's MDS (Minimum Data Set), dated November 2, 2025, shows R1 has severe cognitive impairment, is…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development of pressure sores. This failure resulted in R1 developing a Stage 3 pressure sore to her sacrum. This applies to three of four residents (R1, R3 and R4) reviewed for wounds. Findings include: 1. R1 was admitted to the facility on [DATE] for rehabilitation following a bilateral hip replacement. R1 has diagnoses that includes anemia, morbid obesity, diabetes, urine retention, constipation, anxiety, congestive heart failure, muscle weakness and a history of falling. R1 was discharged from the facility on 11/05/2023. The admission assessment, dated 9/29/2023, identified bruises on R1's left hand and right lower leg. R1's MDS (Minimum Data Set), dated 10/05/2023, indicated she is cognitively intact. The admission assessment identified R1 as being dependent on staff for toileting hygiene, showers / bathing, dressing lower body and personal hygiene. R1 was assessed as completely dependent 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 · F2025-12-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure food was prepared under sanitary conditions and the kitchen was maintained in a clean and sanitary condition. The facility failed to ensure dietary staff utilized hair restrains while preparing food. This failure applies to all 136 residents in the facility. The findings include:On September 29, 2025, at 9:15 AM, V10 (Dietary Aide) walked through the kitchen while assisting with dishwashing, with her hair not completely covered and a large amount of hair exposed from the front and sides of her hairnet. V9 (Dietary Manager) tested the sanitizer levels in the three-compartment sink being used to clean dishes with a result of 150 ppm. On September 30, 2025 at 10:08 AM, V11 (Cook) tested the sanitizer levels in the three compartment currently being used to clean dishes to be between 0 - 150 PPM. V9 said dietary uses Quaternary sanitizer and the levels should be between 200 and 300 parts per million for proper sanitation. On September 30, 2025, at 9:41 AM, V11 (Cook) prepared food, with her hair not…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-04 · 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 standard infection control practices regarding hand hygiene and gloving during provisions of perineum and wound care. The facility also failed to ensure the use of complete PPE (Personal Protective Equipment) for caring of residents who are on EBP (Enhance Barrier Precaution). This applies to 4 of 27 residents (R13, R20, R105, R152) reviewed for infection control in the sample of 27. The findings include: 1. R20's care plan, with a target date of December 1, 2025, shows R20 currently has an abscess to his right buttock. R20 has decreased mobility and requires assistance with ADL (activities of daily living) care. An EBP signage on R20's bedroom door was observed during this survey. On December 1, 2025, at 1:11 PM, V22 (Certified Nursing assistant/CNA) assisted R20 to the toilet. V22 placed a gait belt around R20's trunk, assisted R20 to transfer from wheelchair to the toilet, and pulled R20's pants down prior to sitting on 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-04 · tag F0887 — pattern
  Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
  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 offer residents the updated 2025-2026 COVID-19 vaccine. This applies to 5 of 5 residents (R13, R39, R78, R97, and R112) reviewed for immunizations in the sample of 27. The findings include:1. R13's EMR (Electronic Medical Record) showed R13 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, chronic diastolic heart failure, hypotension, and paroxysmal atrial fibrillation. R13's Immunization Report, dated December 2, 2025, did not show R13 had received or was offered the updated 2025-2026 COVID-19 vaccine. The facility did not have documentation to show R13 was offered the updated 2025-2026 COVID-19 vaccine. 2. R39's EMR showed R39 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including paroxysmal atrial fibrillation, hypertensive heart disease with heart failure, and chronic diastolic heart failure. R39's Immunization Report, dated December 2, 2025,…

  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 · D2025-12-04 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity by maintaining adequate draping and privacy during personal care and assisting a resident in a dignified manner during feeding.This applies to three residents (R31, R107, and R152) reviewed for dignity in a sample of 27.The Findings include: 1.Review of the Electronic Medical Record (EMR) showed R31 is a [AGE] year-old female, with diagnoses including malignant neoplasm of the breast, major depressive disorder, muscle weakness, and basal cell carcinoma. R31's Minimum Data Set (MDS) assessment, dated August 5, 2025, indicated R31 is alert and cognitively intact. The MDS also showed R31 is totally dependent on staff for showering and personal hygiene. R31's care plan, dated November 3, 2025, documented R31 has a self-care deficit related to impaired mobility and requires staff assistance. On September 9, 2025, at 10:43 A.M., R31 was assisted into a wheelchair for a shower. R35 was propelled by V15…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · 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 observation, interview, and record review, the facility failed to safely transfer residents. This applies to 2 of 2 residents (R5 and R105) reviewed for transfers in the sample of 27. The findings include:1. The EMR (Electronic Medical Record) showed R105 was admitted to the facility on [DATE], with multiple diagnoses including spinal stenosis, scoliosis, chronic kidney disease, and other abnormalities of gait and mobility. R105's MDS (Minimum Data Set), dated September 4, 2025, showed R105 was cognitively intact and required moderate assistance from facility staff to come from sitting to standing. R105's fall care plan, dated August 30, 2025, showed,Fall risk related to recent spinal fusion, required ADL (Activity of Daily Living) care assist, decrease in mobility, recent hospitalization, diuretic use, episodes of incontinence. The care plan continued to show multiple interventions, dated August 30, 2025, including, Monitor for safety with transfers and mobility while in room and other common areas. On…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · 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 observation, interview, and record review, the facility failed provide catheter and peri-care in a manner that would prevent urinary tract infection (UTI).This applies to 2 of 4 residents (R20, R152) reviewed for perineum and catheter care in the sample of 27. The Findings include: 1.R20's Face sheet shows R20 is 79 years-old who has multiple medical diagnoses including hemiplegia affecting left non-dominant side, reduced mobility, and personal history of urinary tract infection (UTI). R20's Minimum Data Sheet (MDS), dated [DATE], shows R20 requires assistance with toileting and hygiene and is incontinent of bowel and bladder. On September 30, 2025, at 1:41 PM, V22 (Certified Nursing Assistant/CNA) assisted R20 to the toilet R20 and removed R20's soiled incontinence brief. After R20 completed using the toilet, V22 assisted R20 to get up and proceeded to wipe/clean R20's back perineum only. V22 placed a new incontinence brief to R20 without cleaning R20's groins and frontal perineum. On December 2, 2025,…

  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 · D2025-12-04 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to administer medications as ordered and following standards of care and facility policy. There were 25 medications and 3 errors resulting in a 12% medication error rate. This applies to 1 of 4 residents (R65) reviewed for medication administration in the sample of 27.The findings include:On September 30, 2025, at 9:45 AM, V5 (Nurse) administered multiple medications to R65 including Fluticasone Vilanterol inhaler, Tiotropium Bromide Inhaler, and Mucinex ER (Extended-Release) tablet. V5 administered the two inhalers one after another in less than a minute. V5 also crushed the Mucinex ER when she gave it to R65. On December 2, 2025, at 2:09 PM, V2 (Director of Nursing/DON) stated, <edications that are ER (Extended-Release), or DR (Delayed-Release) should not be crushed because it affects the effect of the medication. Crushing these medications causes immediate release effect in what supposed to be an extended release. V2 also stated when administering inhaler medications, there should be more than a minute in…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were offered the pneumococcal vaccine. This applies to 2 of 5 residents (R13 and R78) reviewed for immunizations in the sample of 27. The findings include:1. R13's EMR (Electronic Medical Record) showed R13 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including dementia, chronic diastolic heart failure, hypotension, and paroxysmal atrial fibrillation. R13's Immunization Report, dated December 2, 2025, showed R13 received the PCV13 (Pneumococcal Conjugate Vaccine 13-Valent) on November 16, 2022. The facility does not have documentation to show R13 was offered additional pneumococcal vaccines. 2. The EMR showed R78 was a [AGE] year-old resident admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's Disease, type 2 diabetes mellitus, and chronic kidney disease. R78's Immunization Report, dated December 3, 2025, showed R78 received the PCV13 on December 1, 2015. 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-11 · tag F0602 — failed to protect residents from theft of their belongings — pattern
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent misappropriation of resident proptery as per the facility abuse policy. This applies to 5 of 6 residents (R1-R4, and R6) reviewed for misappropriation of proptery in a sample of 6. The findings include: 1. Face sheet, dated 2/10/25, shows R1's diagnoses include cellulitis right lower limb, urinary tract infections, atrial fibrillation, dysphagia, lymphedema, depression, chronic kidney disease, and chronic respiratory failure with hypoxia. MDS (Minimum Data Set), dated 1/12/25, shows R1's cognition was intact. On 2/10/25 at 1:37 PM, R1 stated she was called by a convenience store and asked if she made a charge for approximately $21.00 to her credit card at the store. R1 stated she told the store she was residing in the facility for rehabilitation and she had not made any charges to her card since she was admitted at the facility. R1 stated she called her daughter to see if she made a charge, and her daughter told her to cancel the card right…

  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 · Ecited before2024-09-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 observation, interview, and record review, the facility failed to safely reposition a resident and failed to secure oxygen tanks to prevent them from falling and combusting. This applies to 9 of 9 residents (R14, R2, R32, R371, R379, R26, R41, R45, and R84) reviewed for accidents and supervision in a sample of 31. The findings include: 1. R14 was re-admitted to the facility on [DATE], with diagnoses including Parkinson's disease, dementia, muscle weakness, altered mental status, osteoporosis, malignant melanoma of skin, and history of falling. R14's MDS (Minimum Data Set) was not available, but the Significant Change Assessment completed on 9/20/24 showed R14 had moderate cognitive impairment. R14's GG Assessment, dated 9/23/24 showed R14 was dependent on staff for all activities of daily living. On 9/25/24 at 3:23 PM, V8 (CNA/Certified Nurse Assistant) came to R14's room to assist V13 (Wound Care Nurse) and V14 (Wound Care Nurse) with fixing R14's bed height. R14 was lying in bed and the head of 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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

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

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL