Oakwood Rehab and Nursing Center
512 East Ogden Avenue, Westmont, IL 60559 · For profit - Limited Liability company · 149 certified beds · (630) 323-4400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — 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 (63) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $96,215 in federal fines (most recent 2026-04-22)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (62%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.6% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.3% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 88.6% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.7% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.0% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.2% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.9% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 19.1% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.0% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.9% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 3.7% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 17.7% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.7% | 13.9% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.9% 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.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.9%CMS range 28.1–54.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.5%CMS range 8.9–16.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.6%CMS range 4.8–13.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.32 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 149 beds and averages 100.6 residents a day — about 68% occupied, or roughly 48 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 2.88 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.72 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 2.47 hrs/resident/day on weekends vs 3.05 on weekdays — 19% thinner on weekends. RN hours go from 0.52 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 62% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
63 citations, most serious first. The 14 most serious are shown; the remaining 49 are one tap away and print in full.
- Actual harm · Gcited before2026-04-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide supervision for a resident (R2) to prevent a fall. This resulted in R2 obtaining a fracture to her right clavicle. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 6.The findings include:R2's electronic face sheet dated 4/26/26 showed R2 has diagnoses including but not limited to chronic obstructive pulmonary disease, type 2 diabetes, heart failure, depression, muscle wasting and atrophy, and osteoporosis.R2's facility assessment dated [DATE] showed R2 has moderate cognitive impairment.R2's care plan dated 10/14/25 showed, (R2) is at risk for falls related to general weakness, overestimates abilities, poor coordination, unsteady gait, use of narcotics, decreased safety awareness, impulsiveness with attempts to stand or self-transfer without assistance from staff despite repeated direction/education .Interventions: observe frequently and place in supervised area when out of bed, toilet and lay…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-12-12 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was free from verbal and physical abuse. This applies to 1 of 3 residents (R73) reviewed for abuse allegations in the sample of 18. This failure resulted in R73 feeling traumatized, unsafe, being afraid to sleep, and developing insomnia. The findings include: R73's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE], with diagnoses that include Necrotizing Fasciitis, Severe sepsis, Pneumonia, Acute respiratory failure, Alcohol Abuse, and Long Term use of antibiotic. R73's Minimum Data Set (MDS) dated [DATE], showed R73 to be cognitively intact. The initial facility reportable dated November 21, 2024, showed the following: While in the hallway a miscommunication occurred between R73 and V12 (CNA/Certified Nursing Assistant), after which R73 began using his cell phone to video V12. Upon noticing this, V12 moved the phone out of view, which led to R73 becoming upset. The facility's final…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-09-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to perform skin assessments in order to prevent pressure injuries from developing for 1 of 5 residents (R2) reviewed for pressure in the sample of 6. This failure resulted in R2 developing a facility acquired pressure injury that was not identified until it was a Stage 3. The findings include: On 9/3/24 at 11:50 AM, R2 was dressed and sitting bedside in his room. R2 had a low air loss mattress on his bed. R2 said he has a pelvic fracture in two places which causes him some pain. R2 said he is able to walk with a walker, move in bed, and takes himself to the bathroom. R2 said he got the low air loss mattress when they found a sore on his bottom. R2 said he didn't have any sores when he came in. R2's Progress Noted dated 8/6/24 shows R2 was admitted to the facility from the hospital, is alert and oriented to person, place, time, and situation, and is able to make his needs known. The same note shows No open areas, skin is intact. R2's Progress Note dated 8/8/24 shows R2's skin is intact. R2's Progress Note dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-04-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident (R1) was free of physical abuse from another resident (R2) for 2 of 3 residents reviewed for abuse in the sample of 3. This failure resulted in R2 entering R1's room and hitting R1 over the volume of a TV. R1 sustained multiple facial injuries; abrasions to the left hand and ear; and required evaluation and treatment in the emergency room. The findings include: On 4/23/24 at 12:04 PM, R1's frail body was tilted to the right to watch the TV. R1's entire face was covered with bruises of various colors and stages of healing. R1 had a golf ball sized hematoma (blood filled lump) near his left cheek and eye. R1 had a dressing to the left side of his nose. R1's face was swollen, and his facial features were distorted. R1 stated, I was attacked by the guy next door because he said my TV was too loud. That's all I want to say without my lawyer present. R1 used his right arm to hold the remote control and adjust his blankets. R1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-07-01 · tag F0806 — failed to honor food preferences — widespreadEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 that individual food preferences/food choices were assessed, and menus were provided to accommodate those preferences for 6 of 6 residents (R1-R3 and R5-R7) reviewed for food preferences. This failure affects all 102 residents in the facility.Findings include: 1.R1's face sheet shows R1 is a [AGE] year-old female and was admitted to the facility on [DATE], with the diagnoses of quadriplegia, constipation, hematuria, and urinary tract infection. R1's 04/22/2026 MDS (Minimum Data Set) showed R1's cognition was intact.On 06/29/2026 at 12:10 PM, R1 stated that the food here does not taste good. R1 said they give them a piece of plain bread with no spread on their tray most of the time. R1 stated when she was admitted to the facility, no one talked to her about her food preferences, likes, or dislikes. In June, after she had been in the facility for about 2 months, someone from the kitchen came and told R1 she would be getting a menu…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-06-10 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor 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 ensure a comfortable homelike environment due to a lack of supplies needed for basic daily living.This failure affects all 99 residents in the facility.Findings include:1. On 06/06/2026 at 10:01 AM, R2 was in her room watching TV and stated that the facility was short on paper towels, hand soap, and other items, including Kleenex and wipes. R2's sink was located in the bedroom, and the bathroom doesn't have a sink. No paper towels or hand soap were available at the sink.R2's 5/27/2026 MDS (Minimum Data Set) showed R2's cognition was intact and her face sheet showed R3 had hemiplegia, kidney failure, and anemia.2. On 06/06/2026 at 10:36 AM, R3 was in his room and stated he had not been at the facility long, but since he was admitted , the facility has not had enough supplies, including paper towels and soap. R3 stated he gets his own soap, adding nobody seems to care. The paper towel dispenser in R3's bathroom was empty, and the soap dispenser was also empty. There was a small stack of paper towels on the sink…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that residents received provisions of care and services required when a licensed nurse left the assigned unit resulting in lack of consistent nursing supervision and nursing care. This failure directly affected 3 residents (R2, R3 and R7.)The findings include:1.R2 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, asthma, morbid obesity, type II diabetes, anemia, hyperlipidemia, bipolar disorder, anxiety, hypertension, left wrist pain, cellulitis, chronic kidney disease, insomnia, gout, depression, hypoglycemia, depression, hypoxemia. R2's minimum data set (MDS) dated [DATE], showed R2 was cognitively intact.On April 20, 2026, at 10:30 AM, R2 said that on April 04, 2026 at 11:45 PM, R2 hit the nurse call button for anxiety medication. R2 said that V14 (CNA/Certified Nursing Assistant) came into the room and R2 asked V14 to get V18 (LPN/ Licensed Practical Nurse). R2 came back sometime…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-20 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to serve portion sizes as shown on the menu for the lunch meal.This applies to 7 of 13 residents (R2, R4, R5, R10-R13) reviewed for meal prep and service in the sample of 13.The findings include: Facility week at a glance menu for week 4 Tuesday included hamburger as the main entree with sides of seasoned pinto beans and seasoned corn. The menu spreadsheet for the same showed to use #10 scoop plus one ounce broth for the mechanical soft consistency diets.On March 16, 2026 at 12:10 PM, R2 stated The food is horrible. They give you small portions. R2 stated that she receives room trays and that she eats her meals in her room.On March 16, 2026, at 1:43 PM, R4 stated Portions are sometimes good and sometimes not. You could feed your grandkids with the (small) portion they give us. On March 19, 2026, at 11:17 AM, R5 (Resident Council President) stated Often times the residents are complaining that the portions are small and going to the vending machines. When the new company took over the food is really bad. They…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-20 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 review, the facility failed to serve food at a palatable temperature acceptable to residents.This applies to 8 of 13 residents (R2, R4, R9, R5, R10-R13) reviewed for poor preparation/cold foods in the sample of 13.The findings include: On March 16, 2026, at 12:10 PM, R2 stated The food is horrible. Most of the time it is cold. R2 stated that she receives room trays and that she eats her meals in her room.On March 16, 2026, at 1:43 PM, R4 stated Food is hot sometimes but a lot of times it's cold. Most of us eat in the room. On March 17, 2026, at 12:34 PM, R9 stated Food is lukewarm at best. Their carts are a problem. They don't have an efficient way of keeping the food warm or transferring it. R9 stated that he had filed a complaint about a CNA/Certified Nursing Assistant who would not heat up his meal after he had dialysis treatment. R9 continued It takes a lot for me to speak up. But she flipped a switch.On March 19, 2026, at 11:12 AM, R5 (Resident Council President)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-23 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure resident rooms were cleaned routinely for 5 of 6 residents (R1, R6, R11, R12 and R13) reviewed for clean, comfortable and homelike in the sample of 23.The findings include:On 1/23/26 at 9:30 AM, there were no housekeepers seen on the first floor.At 10:01 AM, V14 (Receptionist) was going into resident rooms and emptying their garbage cans.On 1/23/26 at 11:57 AM, R11's bathroom toilet was filled with toilet paper and stool. R11's bathroom smelled of stool. V13, Certified Nursing Assistant (CNA) said that R11's toilet has been in that state for at least three weeks.On 1/23/26 at 12:04 PM, R12's garbage bin in her room did not have a trash bag in it. The garbage bin in the bathroom did not have a trash bag in it as well. R12's room floor was sticky and had splatter marks of an unknown substance throughout the floor. R12 said that she does not remember when the last time was that her floor was cleaned and the spots have been on her floor for at least a month. R12 said that her biggest concern is that when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure staff wore personal protective equipment when caring for residents who are positive for COVID-19 to prevent to spread of infection for 6 of 9 residents (R14-R18 and R20) reviewed for infection control in the sample of 23.The findings include:1.The facility provided COVID Isolation List shows that R20 is on isolation due to being COVID positive. The facility's COVID positive line list shows that R20 tested positive on 1/15/26.On 1/23/26 at 10:01 AM, there was a sign on R20's door that said that she was on contact/droplet Isolation. V14 (Receptionist) was in R20's room. V14 had gloves, gown and a surgical mask on. V14 exited the room with her personal protective equipment still on and disposed of her gown and gloves in a housekeeping cart. 2. The facility provided COVID Isolation List shows that R14 is on isolation due to being COVID positive. The facility's COVID positive line list shows that R14 tested positive on 1/18/26. R17 and R18 are not on the COVID Isolation List.On 1/23/26 at 10:26 AM, R14, R17…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-13 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor 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 supply clean linens in sufficient quantities for resident care needs. This applies to all 98 residents residing in the facility. The findings include: Facility Midnight Census Report, dated 1/30/25, shows the facility census was 98 residents. On 12/30/25 at 2:23 PM on the first floor, the linen carts had only one washcloth and no towels available for resident care. The one washcloth had the seam missing on two sides of the cloth and the edges were frayed. On 12/30/25 at 2:39 PM on the second floor, one linen cart had no washcloths, no bath towels, three bed sheets, 1 pillowcase and 1 blanket. At 2:42 PM on the first floor, a second linen cart had only 1 washcloth, 3 bed sheets, 3 blankets, and 3 gowns on the cart. At 2:45 PM on the first floor, a third linen cart had no washcloths and 2 stained bath towels. On 12/30/25 at 2:46 PM, V2 (Director of Nursing) was shown the stained towel on the linen cart and V2 stated, I wouldn't want to use it. V2 stated the staff call the laundry for linen when needed and the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-13 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed provide timely medication administration per facility policy. This applies to 9 residents (R6, R8, R10, R12, R15, R19, R22, R25, and R27) reviewed for medication administration in a sample of 35. The findings include: 1. The EMR (electronic medical record) showed R19 was cognitively intact. On 12/30/25 at 10:45 AM, R19 (Resident Council [NAME] President) stated the facility residents complain about receiving late medications, waiting long periods for their call lights to be answered, and not having enough staff at the facility. Review of R19 medication administration times on document titled Medication Admin Audit Report showed: -On 1/2/26, Buspirone, Lamotrigine, Dicyclomine was scheduled for 5:00 PM and was administered by the nurse at 6:39 PM. R19's Trazadone, Ezetimbe, Dicyclomine and Lidocaine patch were scheduled for 9:00 PM and was given at 10:22 PM. R19's Mirtazapine was scheduled for 9:00 PM and was given at 10:23PM. -On 1/3/26, Lomotil was scheduled for 4:00 PM and administered by the nurse at 6:26 PM, and R19's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-13 · tag F0725 — failed to have enough nursing staff — patternProvide 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 interviews and record reviews, the facility failed to staff sufficient nurses for proper incontinence care and timely medication administration. This applies to 11 residents (R6, R8, R10, R12, R15, R17, R19, R20, R22, R25, and R27) reviewed for staffing in a sample of 35.The findings include: 1. R17's care plan showed an alteration in skin integrity with a stage 2 pressure sore on the left buttock and is at risk for additional and or worsening of skin integrity issue related to incontinence of bladder, incontinence of bowel, impaired mobility status, diabetes, comorbidities. On 12/31/25 at 12:58 PM, R17 stated he had not had incontinence care since he got out of bed in the morning. V19 (CNA/Certified Nursing Assistant) performed incontinence care on R17 who was wearing two incontinence briefs. R17's brief had a small amount of thick feces and blood, his buttocks, sacrum and scrotum were excoriated, and the left abdominal fold was excoriated and bleeding. R17 stated wearing two incontinence briefs was standard procedure so he did not urinate through his clothing while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 49 citations
- Potential for harm · Dcited before2026-01-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide timely incontinence care to residents who required staff assistance for ADLs (Activities of Daily Living). This applies to 2 of 4 residents (R17 and R20) observed for incontinence care in a sample of 35. The findings include: 1. On12/31/25 at 12:58 PM, R17 stated he had not had incontinence care since he got out of bed in the morning. V19 (CNA/Certified Nursing Assistant) assisted R17 back to bed for incontinence care. R17 was wearing two incontinence briefs. R17's brief had a small amount of thick feces and blood. R17's buttocks, sacrum and scrotum were excoriated, and the left abdominal fold was excoriated and bleeding. R17 stated wearing two incontinence briefs was standard procedure so he did not urinate through his clothing while waiting for assistance. V19 stated she usually placed two incontinence briefs on R17. V19 stated she is unable to get to him with so many people to care for. V19 stated she saw residents every two hours, so she puts the extra undergarment on as a liner to keep his clothes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide incontinence care utilizing techniques per facility protocols and policy. This applies to 3 of 3 residents (R13, R15, and R20) reviewed for incontinence care in a sample of 35. The findings include: 1. On 12/30/25 at 4:12 PM, V6 (CNA/Certified Nursing Assistant) provided incontinence care to R20. V6 opened R20's brief which was saturated with urine and his scrotum was large and reddened. V6 removed the soiled undergarment and wiped R20's penis and scrotum several times with the same washcloth. V6 then wiped R20's feces covered buttocks with the same washcloth and followed with wiping his rectum and buttocks with the soiled washcloth. R20's buttocks were scantly smeared with feces. V6 stated the facility did not use disposable wipes anymore to provide incontinence care and instead use non-disposable washcloths. V6 stated if disposable wipes were available, it would be used once and tossed away. V6 stated the towels usually run out at the facility. V6 stated she only had one towel for the incontinence…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-30 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 cold foods to meet acceptable palatable temperatures requirements for the residents. This applies to 5 of 5 residents (R1, R2, R3, R6, R8) reviewed for poor prep and quality of foods. The findings include: On September 29, 2025, at 9:37 AM, R6 had received a breakfast room tray that was set on a bedside table while he was still in dialysis. The breakfast meal included an 8-ounce carton of whole milk and 4-ounce disposable cup of orange juice. R6 returned to room at around 11:30 AM to eat his breakfast. On September 29, 2025, at 9:44 AM, 10:18 AM and R3 and R1 respectively stated that the food that is supposed to be cold is hot. R3 and R1 added that the orange juice is served warm. On September 29, 2025, at 9:56 AM, R2 stated that cold foods are served warm and that the quality is poor.On September 29, 2025, at 11:33 AM, during tray line service, deli sandwiches wrapped in clear wrap with condiments were seen placed directly on the tray line counter next to the steam table. V10 (Dietary Aide) 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.
- Potential for harm · Dcited before2025-09-30 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to serve protein portion sizes as shown for the lunch meal.This applies to 8 of 10 residents (R1, R2, R3, R4, R5, R6, R7, R9) reviewed for insufficient foods in the sample of insufficient foods in the sample of 10.The findings include:Facility menu spreadsheet for Monday (Week 4) included 6 ounces of Vitamin C juice for breakfast and 3 ounces of Baked Ham as the main entree for lunch.Facility also provided deli sandwiches as a substitute item for baked ham. Nutrition facts on Turkey Deli meat packaging label showed that 4 slices of turkey meat=10 grams of protein.On September 29, 2025, at 9:37 AM, R6 had received a breakfast room tray, and it included a half (disposable) cup of orange juice. R5 was still at dialysis. On September 29, 2025, at 9:44 AM and 10:18 AM, R3 and R1 respectively stated that the drinks served are only half or less than half filled in the cup and watered down. On September 29, 2025, at 9:56 AM, R2 stated that the portion sizes are much smaller and that the resident families have to bring…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 serve palatable meals at temperatures per facility policy. This applies to all 83 residents residing in the facility receiving oral diets. The findings include:Facility Daily Census, dated 9/9/25, shows the facility census was 84 residents. POS (Physician Order Sheet) dated 9/11/25, shows one resident in the facility had a physician order for NPO (Nothing by Mouth).1. On 9/9/25 at 11:17 AM during lunch service, the facility was plating lunch foods which included sweet and sour pork, green beans, white rice and apple sauce. The plate warmer had hot plates in only one of the two sides of the equipment. The warmer had hot plates stacked in one side of the machine and the plates on the cooler side were only slightly warm but not hot. During lunch service, staff transferred some of the cooler plates into the hotter side of the warmer as they served food. At 12:10 PM a test tray was tasted. The pork and rice tasted only slightly warm, and the green beans tasted minimally warm. The temperatures of the pork…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-23 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to accommodate a resident's food allergies and preferences. This applies to 1 of 3 residents (R1) reviewed for food allergies in a sample of 4. The findings include: On 5/20/25 at 12:05 pm, R1 said that she is allergic to shellfish, squash, all melons in the melon family, bananas, and cucumbers. R1 said that she made the facility aware of her allergies, but she continues to be served food she is allergic to. R1 said that on 5/18/25, she was served a salad with a cucumber on it, and she told the staff, and on 5/17/25 she was served melons on her lunch tray, and she told the CNA (Certified Nurse's Assistant). R1 then showed a picture on her phone of a meal tray with a bowl of melons on the tray. On 5/22/25 at 10:45 AM, R1 said that she is still being served food that she is allergic to. R1 said that on the previous Monday (5/19/25) she was served a salad with a cucumber in it again. R1 reiterated that she is allergic to cucumbers, and she has told the facility. On 5/20/25 at 12:59 PM, V4 (CNA) said that R1 has gotten food on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to monitor refrigerator temperatures, failed to label and date potentially hazardous food items, and failed to store food to prevent cross contamination of food items. The facility also failed to ensure dietary staff use facial hair covers while in the kitchen. This failure affects all residents receiving food from the kitchen. The findings include: The facility roster dated December 9, 2024, showed census of 74 residents in the facility. The diet type report dated December 9, 2024, showed 71 residents receive food from the facility's kitchen. On December 9, 2024, at 9:27 AM during the initial tour of the kitchen with V20 (Dietary Manager) the reach in refrigerator #1 had milk and cheeses in it and no thermometer in the refrigerator. The thermometer that is a part of the refrigerator was not functional. V20 stated that staff checks temperatures and records these temperatures in a logbook. The logbook of the refrigerator temperatures for December 5 through December 9, 2024, were reviewed and noted to be blank. V20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-12 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to file and respond to resident grievances in accordance with their policy. This applies to 8 of 8 residents (R9, R10, R14, R15, R23, R49, R56, R61) reviewed for grievances in the sample of 18. The findings include: During the resident interview meeting on December 10, 2024, at 10:05 AM, the consensus of the attendees (R49, R61, R9, R56, R23) was that they were not aware of the facility's grievance process and did not receive feedback from the facility in response to their concerns. V17 (Ombudsman) provided a copy of the facility's grievance form to the resident attendees at the meeting, and the resident attendees stated they had not seen the grievance form before. R61 (Resident Council President) and R49 (Resident Council [NAME] President) both looked closely at the form and stated they had not seen the grievance form before. During the resident meeting, R56 stated she reported to V28 (Social Services/Medical records) during her care plan meeting over the summer, that she was missing clothing items and a phone charger and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-12 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance to residents requiring help with ADL (Activities of Daily Living) care. This applies to 9 of 9 residents (R7, R13, R22, R34, R35, R42, R63, R71 and R72) reviewed for ADL in the sample of 18. The findings include: 1. R34's EMR (Electronic Medical Record) showed R34 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture unspecified joint, and unspecified sequelae of nontraumatic subarachnoid hemorrhage. R34's MDS (Minimum Data Set) dated October 9, 2024, showed R34 had moderate cognitive impairment. R34 was dependent on staff for showering and required substantial/maximal staff assistance with personal hygiene. R34's care plan showed R34 required assistance with ADL care and the intervention included staff to provide assistance with ADL care. On December 9, 2024, at 11:50 AM, R34 was lying in bed wearing a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 to provide incontinence and catheter care in a manner that would prevent urinary tract infections (UTI). This applies to 4 of 6 residents (R7, R10, R13, R56) reviewed for incontinence and urinary catheter care in the sample of 18. The findings include: 1. Face sheet shows R13 is 73 years-old who has multiple medical diagnoses which include personal history of traumatic brain injury, benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, obstructive and reflux uropathy, and unspecified lack of coordination. On December 9, 2024, at 11:20 AM, V25 (Certified Nursing Assistant/CNA) rendered incontinence care to R13 who was wet with urine. V25 wiped R13's groins with wet wipes in a stroke, then she asked R13 to turn on his right side without ensuring that the penile and scrotal area were cleaned. V25 proceeded to remove the soiled incontinence brief and changed it, without wiping/cleaning the rectal and buttocks area. 2. Face…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-12 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide bedtime snacks in accordance with their menu. This applies to 5 of 5 (R9, R23, R49, R56, R61) residents who attended the resident counsel meeting and expressed their concerns regarding the availability of bedtime snacks in the sample of 18. The findings include: On December 10, 2024, at 10:05 AM, during the resident meeting, when asked about the availability of bedtime snacks, R49 (Resident Council [NAME] President) stated they are only served peanut butter sandwiches every night and not all the residents get to have one. R61 (Resident Council President) agreed and stated the staff do not pass out the snacks and only the residents who can get to the nurses' station are able to get the sandwich. R49 resides on the first floor and stated the staff do not pass out the snacks. R61 resides on the second floor. R49 and R61 also stated the peanut butter sandwiches that are served are stale. R9, R23 and R56 all agreed that the bedtime snacks are not passed out by staff, not available to all residents who want them, and only…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement transmission-based precautions as required, failed to perform hand hygiene during provision of care, failed to change gloves during incontinence care and placed soiled linen on the floor. This applies to 7 of 7 residents (R7, R10, R13, R40, R54, R56, R63) reviewed for infection control in the sample of 18. The findings include: 1. R63's EMR (Electronic Medical Record) showed R63 was admitted to the facility on [DATE], with diagnoses that included bilateral osteoarthritis of knees, dementia, acute respiratory failure with hypercapnia, anxiety, and congestive heart failure. R63's MDS dated , November 12, 2024, showed R63 was cognitively intact. R63 was incontinent of both bowel and bladder. R63 required substantial/ maximal assistance with oral care, and personal hygiene (shaving, combing hair, nail care.) R63 was dependent on staff for showering/bathing, and toileting. R63's EMR showed R63 experienced loose stools while receiving…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-12 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide privacy while providing assistance with a shower. This applies to 1 of 1 resident (R15) reviewed for privacy in the sample of 18. The findings include: R15's face sheet showed he is an [AGE] year old male admitted to the facility on [DATE], with diagnoses that includes Obesity, History of Falling, Dependence on Renal Dialysis, and Cerebral infarction. R15's Minimum Data Sheet (MDS) dated [DATE] showed that R15 requires partial/moderate assistance with showering. The same MDS showed that R15 is cognitively intact. On December 11, 2024, at 3:59 PM, while walking down the hall on the way to the nurse's station, surveyor came across a small shower room where R15 was sitting getting assistance with a shower. R15 had no clothing or covering on his body. V31 (Certified Nursing Assistant) had a shower head in her right hand and was holding the door open with her left hand. V31 was spraying water on R15 with the handheld shower head. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct a thorough staff to resident abuse investigation by not reviewing available video footage of the altercation and not requesting the police report of the incident. This applies to 1 of 3 residents (R73) reviewed for abuse allegations in the sample of 18. The findings include: R73's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE], with diagnoses that include Necrotizing Fasciitis, severe sepsis, Pneumonia, Acute respiratory failure, and Long Term use of antibiotic. R73 Minimum Data Set (MDS) dated [DATE], showed R73 to be cognitively intact. On December 9, 2024, at 1:57 PM, R73 stated he was verbally abused and physically assaulted by V12 (Certified Nursing Assistant). R73 stated that he asked V12 at the nurse's station to empty his urinal and she started cursing at him, and she smacked his phone out of his hand. R73 stated he called the police. According to the facility's Final incident reportable dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide a dressing change as needed to a resident with a vascular wound. This applies to 1 of 5 residents (R66) reviewed for wounds in the sample of 18. The findings include: On December 10, 2024, at 4:28 PM, R66 was propelling his wheelchair in the hallway. R66's left leg had a wound dressing which was covered with a tubi-grip that was stained from top to bottom with brown substance. On December 11, 2024, at 9:17 AM, R66 was sitting in his wheelchair in his bedroom, he had the same stained tubi-grip and dressing which was caked with dry brown substance. Upon closer inspection R66's dressing had strong urine odor. On December 11, 2024, at 10:02 AM, V24 (Wound Care Nurse) stated that R66 has a vascular wound on the left leg. His dressing is changed daily and as needed. As needed means to change the dressing if the dressing came off or if the dressing is soiled, this is done to prevent potential infection. On December 11, 2024, at 10:10 AM, V24 rendered wound care to R66. The tubi-grip and dressing was heavily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to assess and provide a brace to a resident to prevent further reduction in ROM (range of motion) and to maintain proper positioning. This applies to 1 of 1 resident (R41) reviewed for range of motion in the sample of 18. The findings include: R41 has multiple diagnoses including nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, paraplegia, anorexic brain damage and contracture of the right and left hand, based on the face sheet. R41's quarterly MDS (minimum data set) dated October 14, 2024, showed that the resident was cognitively intact. The MDS showed that R41 had functional limitation in ROM on both sides of his upper and lower extremities. The same MDS showed that R41 required total assistance from the staff with all of his ADLs (activities of daily living). On December 9, 2024, at 11:24 AM, R41 was sitting in his reclined high back wheelchair, inside his room. R41 was alert, verbally responsive and oriented. With…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to document the dialysis communication and assessment after dialysis. This applies to 1 of 2 residents (R64) reviewed for dialysis in the sample of 18. The Findings Include: R64 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease with dependence on hemodialysis, type 2 diabetes, hemiplegia, and hemiparesis following cerebral infarction and hypotension of hemodialysis. R64's physician order summary showed R64 has an order for in facility hemodialysis 4 days per week and a left arm A-V (Arterial Venous) fistula to the left arm. On December 11, 2024, at 11:30 AM, V18, (Dialysis Registered Nurse) stated after dialysis the facility nurse should assess the fistula for bruit and thrill, check the dressing for bleeding, and check the blood pressure and pulse and assess for any change of condition. V18 stated there is a dialysis communication form that the pre dialysis assessment is documented on by the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-12 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide meaningful activity to a resident who is bed bound and is diagnosed with dementia. This applies to 1 of 4 residents (R7) reviewed for dementia in the sample of 18. The findings include: Face sheet shows that R7 is 60 years-old who has multiple medical diagnoses which include multiple sclerosis, unspecified dementia, unspecified severity with other behavioral disturbance, major depressive disorder, stage 4 pressure ulcer to left and right buttocks, stage 4 pressure ulcer to sacral region, osteomyelitis of vertebra, sacral and sacrococcygeal region, gastrostomy, colostomy, muscle spasm, unspecified pain, major depressive disorder, and anxiety disorder. Minimum Data Set (MDS) dated [DATE], showed R7 is alert and oriented and totally dependent on staff for activities of daily living care. From December 9 through December 10, 2024, there were multiple observations of R7 screaming repeatedly for a nurse to come. On December 9, 2024, at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the kitchen was maintained and food was handled in a sanitary manner for all 84 residents in the facility. The findings include: The Long-Term Care Facility Application for Medicare and Medicaid Form (CMS-671) dated 1/31/24 shows a resident census of 84. On 01/29/24 at 9:50 AM during the kitchen initial tour, at the entrance area of the kitchen, there was a large garbage can with water dripping from an open area of ceiling. The floor surrounding the garbage can had water with white debris from the ceiling tile. The floor was wet with the chalky white debris which continued over to the eye wash station area where there was a floor drain that was clogged full of ceiling tile bits, garbage, and white debris and had standing water. The stove had dried on food forming drips down the side, there was food debris on the floor around the stove and food prep area. The bottom shelf of the food prep table contained two plastic bins of chicken and beef base. The lid to the beef base bin was not secured and on top of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-01 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review the facility failed to wear appropriate Personal Protective Equipment (PPE) in a contact isolation room, failed to provide a resident with clean eating utensils, and failed to keep fingernails at a safe length to prevent the spread of infection. The has the potential to affect all 84 residents residing in the facility. The findings include: The CMS-671 dated 1/30/2024 lists a census of 84 residents. 1. On 1/29/2024 at 10:08AM, Contact Isolation signage was observed on R44's room door and an isolation supply cart were observed outside of the room next to the door. On 1/29/2024 at 10:09AM, V20 Certified Nursing Assistant (CNA) was observed in R44's room with no gown on, touching the resident's bed sheets. On 1/30/2024 at 8:56AM, a spoon was observed lying on the floor of R44's room. On 1/30/2024 at 8:56AM, R44 asked V18 Registered Nurse (RN) to hand her the spoon on the floor. V18 handed R44 the spoon from the floor without sanitizing the spoon. V18 was observed using…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-01 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 cared for in a dignified manner. This applies to 5 of 18 residents (R11, R12, R18, R26 and R75) reviewed for dignity in the sample of 18. The findings include: 1. On 1/29/24 at 10:30 AM R18 stated, V28 (CNA) told me that I am marked as independent, so she does not need to assist me. I just wanted her to put some lotion on me. If I was independent, then I wouldn't be here. R18's MDS (Minimum Data Set Assessment) dated 12/13/23 shows that R18 has no cognitive deficit. On 1/30/24 at 8:30 AM R18 stated, Yesterday after lunch (V28) came in the room and (R11- R18's roommate) asked her, very nicely, what her name was. She wasn't wearing a name tag. V28 responded with, Why? and refused to tell us her name. I found out later what her name was. R11's MDS dated [DATE] shows that R11 has no cognitive deficit. On 2/1/24 at 10:00 AM R12 stated, (V28) lied to me and told me her name was [NAME]. When I talked to the Supervisor about…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-02-01 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide residents receiving a pureed diet with the menu as written. This applies to 4 of 18 (R35, R74, R17, and R22) residents reviewed for menus in the sample of 18. The findings include: Facility provided Puree Diets in Facility sheet shows R35, R74, R17, and R22 receive a pureed diet. On 1/30/24 at 11:53 AM, V15 (cook) plated two puree diet plates with pureed turkey, pureed squash, and pureed bread. The pureed squash was served into a bowl and placed onto the plate with the turkey and bread. Mashed potatoes were not provided. These two plates were then served to R17 and R22 who were sitting at a table in the dining room. R17 and R22's tray tickets from 1/30/24 for lunch show R17 and R22 were to receive pureed turkey, pureed mashed potatoes, pureed squash, and pureed bread. On 1/30/24 at 12:10 PM, V15 plated another puree plate and stated it was for R35. V15 plated a double portion of pureed turkey, a double portion of mashed potatoes, and a single portion of pureed bread. Pureed squash was not provided.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to resolve a resident grievance in a timely manner. This applies to 3 of 18 residents (R18, R47 and R70) reviewed for grievances in the sample of 18. The findings include: On 1/29/24 R18 stated, There are many staff on the phone while providing care. Sometimes it is hard to tell if they are talking to me or to the person in the phone. On 1/29/24 at 10:40 AM, R47 stated, The staff are sitting somewhere and talking on the phone while call lights are going off or they are sitting in the nurse's station and having personal conversations on the phone, happens all the time and it has been going on for months. During the Resident Council meeting conducted on 1/30/24 at 10:30 AM, R70 stated, Staff use cell phones in halls and in resident rooms. They use ear buds, so I don't know if they are talking to me or on the phone. They are not listening to what we say because they are on phone. This happens on every shift. On 1/30/24 at 10:00 AM V31 (Ombudsman) stated, We have been working on these issues for months with no resolutions.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide showers and facial shaving for 2 of 18 residents (R63, R72) reviewed for activities of daily living (ADLs) in the sample of 18. The findings include: On 1/29/24 at 9:50 AM, R63 was in his room sitting in bed. R63's face had a thick growth of prominent whiskers, and his hair was greasy. R63 said he does not usually have a beard or moustache and he likes to keep his face shaved. R63 said they keep promising to take him to the shower, but something always comes up and they don't do it. On 1/30/24 at 9:12 AM, R72 was lying in bed in her room. R72's hair was greasy and there was a foul odor noted. R72 said she only gets showers one to two times a month and that's not enough for her; she needs one more day. On 1/30/24 at 12:04 PM, V3, Certified Nursing Assistant (CNA), said the residents get showers twice a week and include nail trimming, facial shaving, hair and body washing, and applying lotion. V3 said if the residents refuse a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide one-to-one assistance during lunch for a resident with a history of dysphagia and aspiration pneumonia (R17), failed to ensure fall interventions were in place for a resident with a history of falls (R50), and failed to ensure a call assistance device was within reach (R63). This applies to 3 of 18 (R17, R50, R63) residents reviewed for safety and supervision in the sample of 18. The findings include: 1. R17's Face Sheet dated 1/27/24 shows R17 has the following diagnoses: hemiplegia affecting left nondominant side, need for assistance with personal care, other speech and language deficits following cerebral infarction, dysphagia following cerebral infarction, and pneumonia. R17's Physician Order Report dated 1/31/24 shows R17 is to be served a puree diet with honey thick liquids. 1:1 feeding REQUIRED. This order has a start date of 5/15/23. R17's Speech Therapy Treatment Encounter Notes dated 5/16/23 states, . Prior VFSS (Videofluoroscopic Swallow Study) demonstrated aspiration on all other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to honor diet preferences for a resident with a history of significant weight loss. This applies to 1 of 2 residents (R87) reviewed for weight loss in the sample of 18. The findings include: On 1/29/24 at 10:13 AM R87 was seated in his wheelchair in his room. R87 stated, They don't give me the food I order. There are many things I can't eat. Like pasta- too much pasta and I don't eat pasta. I've tried to complain to the office but it is useless. On 01/31/24 at 8:12 AM R87 stated, Last night, I didn't eat. They brought me pasta and the brussel sprouts were too hard. I don't eat pasta and they didn't bring me anything else. On 1/31/24 at 9:20 AM R87 was very upset that staff took his breakfast tray while he was in the bathroom. R87 wanted to show Surveyor that they put gravy all over his bread and he doesn't like gravy. R87 stated that he ate half of it but was upset that it was not to his liking. R87's Physician's Order Sheet dated [DATE] shows…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to accurately and safely dispense medications prior to administration. This applies to 1 of 6 (R44) residents in the sample of 18. The findings include: On 1/30/2024 at 9:00AM, the medication cart V18 Registered Nurse (RN) was using to pass medications had two unlabeled medication cups in the top drawer with medications in them. On 1/30/2024 at 9:00AM, V18 said she had pre-poured the medications for some of the residents because she knew them and could just recheck them prior to giving them. V18 said some of the nurses' pre-pour their medications at the facility. V18 said the medications in the cup were for [R44]. On 1/31/2024 at 9:06AM, V2 Director of Nursing (DON) said medications should not be pre-poured. V2 said the residents' medications should be placed in the medication cup after assessment of the resident and just prior to administration. The facility provided Medication Administration policy reviewed 11/2021 states, Check medication administration record prior to administering medications for the 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.
- Potential for harm · D2024-02-01 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide a pneumococcal vaccine to residents who consented to receive the vaccine for 2 of 5 residents (R13, R41) reviewed for immunizations in the sample of 18. The findings include: On 01/31/24 at 10:11 AM, V19 Infection Control Nurse said the facility did a vaccine clinic in October of 2023 for Flu and Covid 19 vaccinations. V2 Director of Nursing said the facility is doing another vaccine clinic in February for Pneumococcal and RSV vaccines. V2 said vaccines are available from the pharmacy for residents on an individual basis if needed. R13's Informed Consent for Vaccinations dated 10/5/23 shows R13 signed the consent and marked I request the Pneumococcal Vaccine. R13's Preventative Health Care Report dated 1/31/24 shows R13 received only PPSV23 on 11/22/2021 and has not received PCV 15 or PCV20. R41's Informed Consent for Vaccinations dated 9/28/23 shows R41 signed the consent and marked I request the Pneumococcal Vaccine. R41's Preventative Health Care Report dated 1/31/24 shows R41 received an unknown pneumococcal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to develop and implement interventions to manage anxious behaviors for a resident with a diagnosis of dementia. This applies to 1 of 4 (R60) residents reviewed for dementia care in the sample of 18. The findings include: On 1/29/2024 at 10:15AM, R60 said during the night around 2:00AM CNA [Certified Nursing Assistant] named [V21] came into her room to change out her trash and took the cups out of her room. R60 said she likes to have the cups in her room and didn't want them taken out of her room. On 1/30/2024 at 10:36AM, V21 said around 12:30-1:00AM she was doing rounds and emptying trash before she went on her lunch break. V21 said she did go into [R60's] room to empty her trash and did remove some cups sitting on the top of [R60's] bedside table. V21 said [R60] did not want the cups to be taken and became upset. V21 said she left the room with the cups and explained they needed to be cleaned. V21 said [R60] likes to keep the coffee cups in her room. On 1/31/2024 at 9:35AM, V26 CNA said [R60] tends to keep cups on her bedside…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-29 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident who requires dialysis received such services per physician's order. This applies to 1 of 4 residents (R1) reviewed for dialysis services in a sample of 4. Findings include: R1's EHR (Electronic Health Record) showed that R1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including end stage renal disease, acute respiratory failure, hemiplegia and hemiparesis, and cognitive communication deficit. R1's EHR showed that on [DATE], R1 was found unresponsive in the facility, and was transferred to the local community hospital. R1's Death Certificate certified date of [DATE] showed that R1 was dead on arrival to the hospital on [DATE]. R1's death certificate showed cause of death was due to End Stage Renal disease and Diabetes Mellitus. R1's [DATE] physician's order showed hemodialysis (external to facility) once a day on Tuesday, Thursday, and Saturday, repeat every week. R1's [DATE] physician's note showed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-12-14 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve the correct portion sizes to 70 residents receiving regular diet, 8 receiving Mechanical soft diets, and 7 receiving puree diets, reviewed for insufficient food service. This has the potential to affect all 85 residents residing in the facility. The findings include: 1.) On 12/12/23 at 11:30am on the second floor a small kitchenette had V4 [NAME] and several staff preparing plates for all of the residents at the facility. The Menu on the wall outside of the dining room showed residents were having cabbage rolls, broccoli, fruit cup, bread and a chocolate chip cookie. V4 (Cook) was serving cabbage rolls, broccoli with a dinner roll. V4 stated, Each resident gets one cabbage roll and a number 3 Spoodle of broccoli and a dinner roll. The cabbage rolls were uneven in size and a lot of filling spilled out of the roll while transferring to a plate. V4 at times would scoop up filling from the side of the pan and put it on the plate. One…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure a clean environment for food preparation and service. The facility failed to monitor sanitization methods for dishware. This applies to 84 of 85 residents reviewed for food storage and preparation. The findings include: On 12/12/23 at 10:30am upon entering the kitchen on the main floor there are no paper towels in the kitchen for drying hands. V4 [NAME] stated, We only have napkins right now. V4 provided one napkin for drying hands. The handwashing sinks are dirty with debris. There was a dirty dumpster approximately 5 feet from the stove and prep area without a lid. The dumpster was full of garbage and refuse. Flies were noted coming out of the dumpster. Next to the food prep table food staff coats were hanging with the arms of the coats touching the prep area. There was a cell phone and an employee's mug next to the coats on the prep table. The prep table had hamburger buns, tortillas, sliced tomatoes, pureed rice and lettuce on the table with the personal items. Several food carts next to the prep…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-13 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide palatable meals to residents receiving oral diets. This applies to 4 of 5 residents (R1, R3, R4 and R5) reviewed for meals in a sample of 5. The findings include: 1. On 9/11/12 at 12:26 PM during lunch service on the second floor with V10 (Food Service Manager), a test tray was evaluated during lunch service. The test tray was plated and placed on the food cart at 12:26 PM in the main dining room on the second floor. The tray remained on the food cart until the last tray was served to a resident from the cart at 12:57 PM. The temperature of the pork entree of the test tray measured 100 degrees F (Fahrenheit) and the pork tasted lukewarm. V10 tasted the pork and stated the pork tasted luke temperature. The temperature of the baked potato measured 110 degrees F and tasted lukewarm. The temperature of the peas measured 105 degrees F and also tasted lukewarm. 2. MDS (Minimum Data Sheet), dated 8/18/23, shows R1 was cognitively intact.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-03 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care and failed to ensure that grooming and hygiene are provided. This applies to 4 of 5 (R2, R3, R4, R5) residents reviewed for activities of daily living from the total sample of 11. The findings include: 1. R2's face sheet shows that R2 is 78 years-old and has multiple medical diagnoses which include morbid obesity, weakness, stage 3 chronic disease and urinary tract infection (UTI). Minimum Data Set (MDS) dated [DATE] shows that R2 was alert and oriented and requires extensive activities for toileting and grooming/hygiene care. R2's active care plan shows that R2 has bladder and bowel incontinence related to cardiomyopathy, sepsis, lymphedema, anemia, gout, lack of coordination, muscle weakness and decrease endurance. On 8/1/23 at 11:14 AM, R2 was resting in bed and was awake. R2 stated that she needs her incontinence brief to be change. Her last incontinence care was at 5:00 in the morning. On 8/1/23 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-03 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that medications are given according to physician's order. There were 26 medication opportunities with 7 errors resulting to 26% medication error rate. This applies to 5 of the 7 residents (R7, R8, R9, R10, R11) reviewed for medication administration in the sample of 11. The findings include: 1. Face sheet shows that R7 has multiple medical diagnoses which include hypertensive heart disease with heart failure, type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hereditary and idiopathic neuropathy, unspecified tremor, and vascular dementia. On 8/2/23 at 10:44 AM, V4 (Nurse) administered multiple medications to R7 which include one tablet of Levetiracetam 500 milligrams (mg), and one tablet of Metoprolol 25 mg. In addition, V4 checked R7's blood glucose level (BGL) which showed 306 milligram/deciliter (mg/dl). On 8/2/23 at 11:29 AM, V4 administered 11 units of Insulin Lispro to R7. R7's medications administration history/record for the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-08-03 · tag F0760 — failed to prevent significant medication errors — patternEnsure 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 observation, interview, and record review, the facility failed ensure that residents are free of any significant medication errors during medication administration. This applies to 5 of 8 residents (R1, R7, R9, R10, R11) reviewed for medications in the sample of 11. The findings include: 1. R1's face sheet shows that R1 is 61 years-old and has multiple medical diagnoses which include chronic atrial fibrillation, chronic kidney disease and type 2 diabetes mellitus. Minimum Data Set (MDS) dated [DATE] shows that R1 is alert and oriented. On 8/2/23 at 10:47 AM, R1 was resting in bed, awake, alert and oriented. R1 stated that sometime last week his medications were all late. These were morning medications that are 5 hours late, including his insulin for his diabetes and antibiotic for his urinary tract infection (UTI). It doesn't happen just once, there are times that nurses were late with passing the medications. Sometimes the morning medications becomes afternoon medications. R1 was unable to recall the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-15 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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 observation, interview and record review the facility failed to ensure there was a sufficient number of staff to provide nursing services to assure resident safety and maintain their well-being according to their plan of care. This applies to all 84 residents residing in the facility. The findings include: The Resident Census and Conditions of Residents Form (CMS-672) dated 3/13/23 shows that there were 84 residents residing in the facility. 1. On 3/13/23 at 9:30 AM, R32's fingernails were very long and had dirt underneath them. His toenails were also long. R32 said, We are supposed to get showers 2 times a week, but I have not been getting my showers. I had not had one in over 2 weeks. I honestly do not even know when my shower days are anymore, it seems only certain CNA's (Certified Nursing Assistants) will even give me my shower. My fingernails are so long and probably have dead skin underneath them. I had to ask my sister when she visited a while back to cut them because no one here does. We wait a long time for our call lights to be answered and a while back I had an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-03-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to store food in a sanitary manner. This applies to all 84 residents residing in the facility. The findings include: The Resident Census and Conditions of Residents Form (CMS-672) dated 3/13/23 shows that there were 84 residents residing in the facility. On 3/13/23 at 9:22 AM, the walk-in freezer had a box of cooked Italian sausage on a shelf. The box was located directly under the condenser. The box had a large amount of ice buildup on top of the box. On 3/13/23 at 9:22 AM, V4 (Dietary Manager) said that he does get ice buildup on the unit every once in a while, that he has to chop off and he is not sure why. V4 said that he has not put in a request for maintenance of the unit. On 3/13/23 at 9:25 AM, there were large white bins of corn meal, thickener, oatmeal and flour in the dry storage room. The thickener bin and oatmeal bin lids were halfway open. The flour bin had a label on it that said, Use by 12/27/22. The thickener, oatmeal and corn meal bins did not have a label of the date that the food was put in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-03-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 serve food at an appetizing temperature for 6 of 22 residents (R29, R37, R41, R73, R332 and R333) in the sample of 22. The findings include: On 3/14/23 12:21 PM, an insulated cart was delivered to the second floor with the noon meal trays inside. At 12:24 PM, V5, Certified Nursing Assistant (CNA) opened both doors to the insulated cart. V5 then went to assist a resident out of the bathroom. At 12:28 PM, V5 started passing trays. V5 passed trays and answered call lights by herself until 12:48 PM. At 12:48 PM, V6 (CNA) arrived on the floor. The last tray was delivered to R41 at 1:00 PM. During the passing of trays, the insulated cart doors remained open. On 3/14/23 at 12:44 PM, V5 said that she was not sure where the other CNA was at. At 12:48 PM, V6 said that she had just returned from break. On 3/14/23 at 1:00 PM, R41 said that her noodles were cold, and food is often delivered cold. During the Resident Council Meeting on 3/14/23 at 9:47 AM, R37 and R29 said that the food is frequently cold. R37 said that his…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure nail care was provided for 1 resident (R32), failed to ensure incontinence care was provided in a timely manner for 2 residents (R32, R332), and failed to ensure showers were provided for 2 residents (R19 and R32). This applies to 3 of 22 residents (R19, R32 and R332) reviewed for Activities of daily living (ADL's) in the sample of 22. The findings include: 1. On 3/13/23 at 9:30 AM, R32 was lying in bed. His fingernails were very long and had dirt underneath them. His toenails were also long. R32 said, We are supposed to get showers 2 times a week, but I have not been getting my showers. I had not had one in over 2 weeks. I honestly do not even know when my shower days are anymore, it seems only certain CNAs (Certified Nursing Assistants) will even give me my shower. My fingernails are so long and probably have dead skin underneath them. I had to ask my sister when she visited a while back to cut them because no one here does. We wait a long time for our call lights to be answered and a while back I had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide oral care and treatments for a resident with mouth ulcers and failed to ensure wound treatments were completed as order for a resident with a non pressure wound for 2 of 22 residents (R21, R54) in the sample of 22. The findings include: 1. On 03/13/23 at 9:31 AM, R21 had brown crusty debris in the right corner of the mouth. R21's tongue was dry and crusty brown with visible cracks, R21's teeth and gums had brownish debris. R21 stated my mouth is so dry. They don't swab it or brush my teeth. It's like hands off, out of site out of mind. I have no appetite because of my mouth pain. R21's breakfast tray was untouched on the bedside table and the water cup was empty. There were no mouth swabs observed in the room. On 03/14/23 at 9:45 AM, R21 was crying and stated my mouth is no better. It's terrible. It's cracking on the inside. They did swab my mouth a few times yesterday evening, and it helped but it's so sore. I don't get the mouthwash hardly ever. On 03/14/23 at 11:10 AM, V13 Dietician said she just…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure pressure injury interventions were administered as ordered and failed to ensure dressing changes were performed in a manner to prevent infection for 2 of 6 residents (R21, R51) reviewed for pressure in the sample of 22. The findings include: 1. On 03/13/23 at 9:46 AM, V12 Wound Licensed Practical Nurse and V23 Certified Nursing Assistant went into R21's room to perform wound care. R21 was rolled to her right side. R21 had a colostomy bag on her left abdominal area and an indwelling urinary catheter. R21 had an incontinence brief on that was visibly saturated with old blood looking drainage mixed in with dark brownish yellow. This surveyor was able to smell the foul odor before the brief was removed, while wearing an N95 mask. V23 undid the tape on the right side on R21's incontinence brief and when she let go of the tape the brief was so saturated it fell off by itself onto the bed. The gauze and foam dressing were not adhered to R21 and fell off with the incontinence brief. The foul smell of purulent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure restorative services were being provided to 1 of 12 residents (R73) reviewed for restorative in the sample of 22. The findings include: On 3/13/23 at 10:20 AM, R73 said I am supposed to be receiving restorative services and be walked so far down the hall and back every day but that is not happening. R73's active restorative care plan initiated on 12/27/23 shows he will be ambulated 50 feet with a walker and gait belt and wheelchair follow up staff assistance, 6-7 days a week. R73's Point of Care (POC) Restorative charting shows from the period between 2/8/23 and 3/15/23 R73 was walked on only the following days: 2/12/23, 2/16/23, 2/17/23, 2/20/23, 2/22/23, 2/26/23, and 3/14/23 (7 out of 36 days). On 3/14/23 at 11:56 AM, V10 (Restorative Nurse) said, Restorative documentation is done in the POC section in the residents electronic medical records. I update the resident care cards and care plans and check to make sure restorative care is being done. There was a period where both myself and the restorative CNA (V18)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident, at risk for choking and aspiration, consumed foods that were pureed in consistency. The facility failed to ensure a resident was transferred in a safe manner. The facility failed to identify and assess a resident at risk for elopement. These failures apply to 3 of 22 residents (R78, R33, R25) reviewed for safety and supervision in the sample of 22. The findings include: 1. R78's care plan dated January 10, 2023, showed R78 had diagnoses of dysphagia and esophageal cancer. R78's Speech Therapy Evaluation and Plan of Treatment dated February 20, 2023, showed R78 required a pureed diet due to his diagnosis of dysphagia and risk of aspiration. On March 13, 2023, at 9:40 AM, R78 was sitting in bed, coughing at times. A small box of Cheerios (cereal) was noted on R78's bedside table. Next to the cereal box was a small rectangular plastic bowl that contained a moderate amount of watery, partially digested, cereal. No staff were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to maintain urinary indwelling catheters in a manner to prevent infection for 2 of 8 residents (R60, R21) reviewed for urinary catheters in the sample of 22. The findings include: 1. On 03/13/23 at 10:37 AM, R60 was in bed with his urinary catheter drainage bag hanging on the bed frame. The drainage tube end was sticking out of the catheter bag, exposed to the air (not secured inside of the pocket on the urinary bag.) On 03/14/23 at 10:40 AM, R60's urinary catheter drainage bag was hanging on the bed frame with the drainage tube sticking out with the end exposed and touching the bed frame. R60 stated I've had the urinary catheter for about 1.5 years now and have had a few infections. On 03/14/23 at 10:55 AM, V24 Certified Nursing Assistant stated, when we empty the catheter, we are supposed clean the drainage tube and put in back up in the sleeve for protection and so it doesn't drip on floor or touch something dirty. On 03/14/23 at 12:54 PM, V2 Director of Nursing said catheters should be placed below the level…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to feed and/or provide assistance with eating to residents with significant weight loss. These failures apply to 2 of 13 residents (R4, R67) reviewed for weight loss in the sample of 22. The findings include: 1. R4's current care plan showed R4 was cognitively impaired with diagnoses of dementia and dysphagia. The care plan showed R4 was on a pureed diet with a history of significant weight loss. The care plan showed R4 will lose no body weight by next review . R4's Vitals Report printed March 14, 2023, showed R4 weighed 104 pounds (lbs) on 11/4/22 and 92.2 lbs on 2/8/23 which showed a significant weight loss of 11.4% in three months. The report showed R4 weighed 92.2 lbs on 2/8/23 and 87 lbs on 3/6/23 which showed a significant weight loss of 5.6% in one month. On March 13, 2023 at 9:24 AM, R4 was asleep in bed. R4's pureed breakfast tray was noted on R4's bedside table. R4's food tray remained covered. No staff were present in R4's room. On March 13, 2023, at 9:37 AM, R4 remained asleep in bed. R4's food tray…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 (at ordered times or in ordered dosage). There were 34 opportunities with 12 errors resulting in a 35.29% error rate. This failure applies to 2 of 7 residents (R67, R36) observed in the medication pass. The findings include: 1. R67's March 2023 Medication Administration Record showed physician orders for R67 to receive Allopurinol 100 mg (milligram), Enteric Coated Aspirin 81mg, Multi-Vitamin with Minerals 1 tablet, Omeprazole 40mg, and Prostat Liquid Supplement 30 mls (milliliters), daily, at 9:00 AM. On March 13, 2023, at 11:17 AM, V28 Registered Nurse (RN) administered R67's scheduled 9:00 AM medications (Allopurinol, Aspirin, Multi-Vitamin, Omeprazole, Prostat) to R67. When V28 RN was asked why R67's medications were administered late, V28 stated, They are late because I am an agency nurse and don't know these residents. 2. R36's March 2023 Medication Administration Record showed physician orders for R36 to receive Chewable Aspirin 81mg, Folic Acid 1 mg, Glimepiride 1 mg,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-03-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure medications were administered on time to prevent a significant medication error for 1 of 22 residents (R282) reviewed for medications in the sample of 22. The findings include: On 3/13/23 at 10:24 AM, R282 said, Yesterday (3/12/23) my morning medications that I should get at 9:00 AM, came at 12:15 PM (3 hours and 15 minutes late). I take a medication for heart irregularity 3 times a day and that is supposed to be at 9:00 AM, 1:00 PM, and then 5:00 PM. The nurse then came and gave me the 1:00 PM dose at 1:45 PM even though I just had it 1.5 hours before that. The nurse then tried to give me the 5:00 PM dose but I refused to take it because I had too many doses close together. My heart medication is a serious thing, and I should be getting them on time I get abnormal heart beats if I don't. I did call yesterday and report this to (V17) who is a Social Worker. On 3/14/23 at 8:21 AM, V1 (Administrator) said they had a issue with a nurse being a no show on 3/12/23 and were unable to find anyone to replace her and that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-15 · tag F0919 — failed to provide a working call system — isolatedMake 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a residents room had a functioning call light for 1 of 22 residents (R59) reviewed for call lights in the sample of 22. The findings include: On 03/13/23 at 9:56 AM, R59 was in bed in her room. R59 stated my call light is not working. I need a new bulb. I have no way of getting help. There is not maintenance guy now. I told them days ago, but they just say I'm on the list. R59 pushed the call light and the red light in the room on the call light plate on wall came on but the light outside the room did not. On at 03/14/23 9:15 AM, R59 stated the call light still doesn't work, no one fixed it yet. On 03/14/23 at 10:55 AM, V24 Certified Nursing Assistant stated room [ROOM NUMBER]'s call light doesn't work. The bulb doesn't work, the red light works in room, but the bulb doesn't come on in the hall. It doesn't beep at the nurses station either. No one was in the room until her, R59's been there a week and it hasn't worked the whole…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$96,215 in federal fines across 4 penalties.
- $19,135 — penalty dated 2026-04-22
- $27,641 — penalty dated 2025-09-12
- $36,230 — penalty dated 2024-12-12
- $13,209 — penalty dated 2024-08-30
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 ATIED ASSOCIATES — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.8 | -0.8 vs chain |
| Health inspection | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 1 of 5 | 1.8 | -0.8 vs chain |
| Quality measures | 3 of 5 | 3.2 | -0.2 vs chain |
The other 11 homes this chain runs (chain average 1.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ROTHNER, WILLIAM | Individual | CORPORATE DIRECTOR | since 11/01/2018 |
| PRETTER, MOSHE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/20/2021 |
| ATIED ASSOCIATES LLC | Organization | ADP OF THE SNF | since 11/01/2018 |
| EXTENDED CARE CLINICAL LLC | Organization | ADP OF THE SNF | since 11/01/2018 |
| EXTENDED CARE CONSULTING LLC | Organization | ADP OF THE SNF | since 11/01/2018 |
| ROTH & CO, LLP | Organization | ADP OF THE SNF | since 01/08/2025 |
| SIDDIQUE, MOHAMMAD | Individual | ADP OF THE SNF | since 03/01/2023 |
CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 85% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145338. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-12, 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.