Aperion Care Wilmington
555 West Kahler, Wilmington, IL 60481 · For profit - Limited Liability company · 171 certified beds · (815) 476-2200 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 3 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (50) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $293,067 in federal fines (most recent 2025-02-14)
- 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)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| 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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.4% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.9% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 93.8% | 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 | 3.6% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.9% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 20.3% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 92.3% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.2% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.4% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 71.8% | 21.7% | 17.1% | check this† — see note marked dagger below the table |
| Short-stay residents who newly got an antipsychotic medication | 6.8% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 70.8% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 28.9% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 9.0% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.79 | 2.02 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.49 | 2.22 | 1.80 | better |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.06 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 30% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.6%CMS range 5.8–15.6 | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 | 3.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 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 171 beds and averages 161.1 residents a day — about 94% occupied, or roughly 10 beds typically open. It runs fairly full. 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 2.15 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 1.26 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 1.94 hrs/resident/day on weekends vs 2.23 on weekdays — 13% thinner on weekends. RN hours go from 0.51 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
50 citations, most serious first. The 16 most serious are shown; the remaining 34 are one tap away and print in full.
- Immediate jeopardy · Lcited before2024-09-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure food was stored, distributed, and served to residents in a manner to prevent food contamination. The facility failed to have a system in place for sanitizing dishware and food service equipment during the renovations of the kitchen. This failure resulted in the local health department revoking the facility's permit to prepare food on site and resulted in an Immediate Jeopardy. This has the potential to affect all 161 residents that consume food from the facility. Finding include: The Immediate Jeopardy began on August 26, 2024, when the facility's kitchen was closed for floor repair and food preparation continued in the facility without the ability to maintain safe food temperatures and sanitize food service equipment and dishware. As a result, the local health department revoked the facility's permit to prepare food on August 27, 2024. On August 28, 2024, the facility was still attempting to prepare puree and mechanically altered…
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.
- Immediate jeopardy · Jcited before2023-11-21 · 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
Based on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from abuse. This failure resulted in R2 being physically abused by V5 (Certified Nursing Assistant/CNA) on 11/2/23; R2 complaining of leg pain and limping on 11/5/23; a new order for morphine sulfate every six hours for pain being placed on 11/6/23; and R2 using a wheelchair for leg pain relief. The findings include: The Immediate Jeopardy began on 11/2/23 at 9:00 PM when V3 (CNA) and V4 (CNA) witnessed V5 (CNA) physically abusing R2 during nighttime cares. V1 (Administrator) was informed of the Immediate Jeopardy on 11/17/23 at 1:03 PM. The surveyors confirmed by observation, interview, and record review, that the immediacy was removed on 11/20/23, however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R2's admission Record, printed by the facility on 11/16/23, showed she had diagnoses including severe dementia, senile degeneration of brain, adult failure to thrive, 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.
- Immediate jeopardy · Lcited before2023-09-12 · 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
Based on observation, interview and record review, the facility failed to identify an infectious outbreak, implement measures to prevent the spread of this infectious outbreak, and failed to have an infection control program in place to monitor and track infectious diseases at the facility. This failure has the potential to affect all 166 residents residing at the facility. The Facility Data Sheet dated 8/29/2023 documents 166 residents reside at the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/11/2023 at 12:37 PM after R1 tested positive for scabies and the facility failed to implement measures to prevent the spread. The Immediate Jeopardy was identified on 9/7/23. V1 (Administrator) was notified of the Immediate Jeopardy on 9/7/23 at 9am. The surveyor confirmed by observation, record review and interview that the immediacy was removed on 9/12/2023, non-compliance remains at a Severity Level Two due to the need to evaluate the implementation of policies and procedures, audits, and quality assurance monitoring. Findings include: 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.
- Actual harm · Gcited before2026-06-04 · 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 protect the residents' rights to be free from verbal and physical abuse by a resident who frequently demonstrated verbal and physical abuse to others in the facility. This applies to 4 of 6 residents (R20, R37, R93, R145) reviewed for abuse in the sample of 33. A reasonable person would feel targeted, paranoid, and not safe based on R133's behaviors and physical abuse to other residents. The findings include: 1.R145's Face sheet shows that R145 has multiple psychiatric diagnoses including schizophrenia and generalized anxiety. Minimum Data Sheet (MDS) March 10, 2026, shows R145 is alert and oriented. R145's Abuse/Neglect Screening dated June 1, 2026, shows he was at risk for abuse. R145's incident report dated March 12, 2026, shows R145 had an altercation with R133. On June 1, 2026, at 11:33 AM, R145 was walking in the hallway when R133, who was in his wheelchair, came up behind R145 and suddenly struck R145 in the middle of his lower…
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 before2025-05-02 · 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 protect a cognitively impaired resident who is at risk for abuse (R1) from being physically and emotionally abused by another resident (R2). The facility also failed to develop interventions to address the potential for abuse for two of three residents (R1, R2) reviewed for abuse in a sample of 4. This failure resulted in R2 physically slapping R1 on the face, scratching R1's upper body, and biting R1's hand, which caused R1 to experience emotional distress. Findings include: Final facility incident report documented the following: On 04/20/2025, R1 and his roommate R2 had an alleged resident to resident behavior and were immediately separated and assessed for injuries. Both residents have Dementia. Upon assessment for injuries, none were noted to R2. R1 was noted with superficial scratches to face and right earlobe, and left knee, a discoloration to the upper lip and left had middle finger, which have all healed. R1 was moved to another…
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 before2025-02-14 · 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 residents were free from physical abuse. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 4. This failure resulted in R1 being bitten by R2, causing bleeding, hospital transfer, and antibiotic therapy for injury. The findings include: R2 is a [AGE] year-old male admitted with moderate cognitive impairment as per the MDS dated [DATE]. R2 was admitted with an admitting diagnosis including anxiety, dementia with behavior disturbance, cognitive communication deficit, and schizophrenia. R1's diagnosis includes moderately impaired cognition, as per the Minimum Data Set (MDS) dated [DATE]. R1 had an admitting diagnosis, including alcohol-induced persisting dementia, anxiety, depression, and Alzheimer's disease. 1/28/25 3:21 PM nurses note for R1 from V3 (Agency Licensed Practical Nurse/LPN) documents in part 930am Resident noted large bite mark on left arm. CNA (Certified Nursing Assistant) report a resident 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 · Ecited before2026-07-01 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to protect the residents' right to be free from physical abuse by another resident. This applies to 4 residents (R1, R2, R3 and R4) reviewed for abuse in a sample of 5. Findings include:1. On 07/01/26 at 12:03 PM, R1 stated he got into an altercation with R2. R1 stated he was attempting to pass R2 in the hallway when he accidently bumped into him. R1 stated he attempted to apologize when R2 hit him. R1 stated he then grabbed R2 by his collar and R2 bit his right thumb on the knuckle. R1 stated he got antibiotics for the bite, but his thumb still hurt. R1 stated the staff broke them up but he did not recall their names. R1's right thumb appeared slightly reddened and swollen. On 07/01/26 at 12:10 PM, R2 stated he did not recall getting into an altercation with anyone. On 07/01/26 at 12:29 PM, V3 (Registered Nurse/Assistant Director of Nursing) stated while she was providing care to another resident, she heard a commotion from the hallway. V3 stated she came out to find R1 and R2 fighting. V3 stated she and CNAs…
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 before2026-07-01 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse. This applies to 4 residents (R1, R2, R3, R4) reviewed for abuse investigations in a sample of 5 residents.The findings include: 1.The facility's final Facility Reported Incidents for R3 and R4's physical abuse altercation listed the event as an accident/incident rather than resident abuse. The form showed an altercation was alleged and R4 sustained a scratch on her right cheek that required first aid. The form showed Upon investigation, [R3] was upset.[R4] reached out to [R3] in the hallway encountering her causing a small scratch. No conclusion was included on the form to show if abuse/assault did or did not occur. On 7/1/26 at 9:45AM, V1 (Administrator) was asked for her complete investigation file of the Facility Reported Incident from 6/13/26 between R3 and R4. V1 provided the initial and final reports that were sent to the state surveying agency and was unable to provide any additional evidence such as interviews with staff witnesses or documentation or observations of R4…
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 before2026-04-30 · 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
Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident. This applies to 1 resident (R2) reviewed for abuse in a sample of 3 residents. The findings include:On 4/29/26 at 10:49 AM, R2 said R1 attacked him. R2 said R1 kicked him in his left knee and R3 witnessed it. R2 said he wants to press charges against R1, but up front they are acting like nothing even happened. R2 said the police never interviewed him about the incident.On 4/29/26 at 10:59 AM, R3 said she witnessed the altercation between R1 and R2. R3 said R1 got aggressive with R2 and started grabbing R2's legs to try to push him down. R3 said when R2 didn't fall, R1 kicked R2 in his left knee and then R2 fell and landed on his left hip.On 4/29/26 at 11:07 AM, R1 said he kicked R2.On 4/29/26 at 1:25 PM, R2 said when R1 kicked him, it knocked him off his feet. R2 said he fell on his left hip and has continued to have pain in his hip since R1 knocked him down. R2 rates his hip pain as a 5/10 on a 0-10 scale. R2 said he has pain when he walks and 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 · Dcited before2026-04-30 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report a resident to resident abuse allegation to the state surveying agency and to the police. This applies to 2 of 2 residents (R1,R2) reviewed for abuse in a sample of 3 residents.The findings include:On 4/29/26 at 10:49 AM, R2 said R1 attacked him. R2 said R1 kicked him in his left knee and R3 witnessed it.On 4/29/26 at 10:59 AM, R3 said she witnessed the altercation between R1 and R2. R3 said R1 got aggressive with R2 and started grabbing R2's legs to try to push him down. R3 said when R2 didn't fall, R1 kicked R2 in his left knee and then R2 fell and landed on his left hip.On 4/29/26 at 11:07 AM, R1 said he kicked R2.On 4/29/26 at 1:39 PM, V7 (Licensed Practical Nurse/LPN) said R1 kicking R2 is a reportable incident and that was why she reported it to V1 (Administrator) immediately.On 4/29/26 at 2:05 PM, V8 (Certified Nursing Assistant/CNA) said he witnessed on 4/25/26 R1 aggressively grabbing R2's leg and shaking it to try to get R2 to fall, but when R2 stayed upright, R1 kicked R2 in his left leg and R2 fell. V8…
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 · E2026-03-17 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to ensure residents have a safe, functional, sanitary, and comfortable restroom environment. This applies to 18 of 18 residents (R3, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24) reviewed for restroom environment in sample of 24.The findings include:On March 12, 2026, at 1:32 PM, V3 (Environmental Manager) said that some residents have shared restrooms, while others have private rooms. She said each housekeeper has assigned residents' restrooms and bedrooms to clean daily. V3 said the day shift housekeepers clean the residents' bedrooms and bathrooms, including the toilets, sinks, soap, and paper towel dispensers daily. V3 said the housekeepers clean the residents' dining rooms after mealtimes, three times a day.On March 12, 2026, at 1:44 PM, the shared bedroom restroom for R3, R20, R21, R22, R23, and R24 was inspected in the presence of V3. There were toilet papers on the restroom floor, and the floor also had scattered black, stained footprints. There was a blue cloth bed pad with large…
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 before2026-03-17 · 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
Based on interviews and record review, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include:On March 13, 2026, at 3:00 PM, R2 was walking around at his bedside and the doorway of his room. R2 said he got into a fight with his roommate (R1) in the dining room on March 12, 2026. R2 said, he got in my face, and I pushed him. R2 said when he pushed R1, R1 fell out of his wheelchair and was able to get up on his own. On March 13, 2026, at 3:15 PM, R1 was in the day room in his wheelchair. R1 said he was in the dining room on March 12, 2026, around 7:00 AM, when R2 approached him and started yelling at him, and suddenly pushed him out of his wheelchair. R1 said it happened so fast, and there was another resident in the dining room, but he did not remember the resident. R1 said there were no staff present in the dining room with them, and no staff saw what happened. R1 said he felt bad that someone attacked him at his place of residence. 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 · Dcited before2026-03-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to report an accurate allegation of abuse to the state surveying agency in a timely manner. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include:On March 13, 2026 at 3:00 PM, R2 was walking around at his bedside and the doorway of his room. R2 said he got into a fight with his roommate (R1) in the dining room on March 12, 2026. R2 said, he got in my face, and I pushed him. R2 said he pushed R1, and R1 fell out of his wheelchair and was able to get up on his own. On March 13, 2026, at 3:15 PM, R1 was in the day room in his wheelchair. R1 said he was in the dining room on March 12, 2026, around 7:00 AM, when R2 approached him and started yelling at him, and suddenly pushed him out of his wheelchair. R1 said it happened so fast, and there was another resident in the dining room, but he did not remember the resident. R1 said there were no staff present in the dining room with them, and no staff saw what happened. R1 said he felt bad that someone attacked him at his place of residence.…
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 before2026-03-17 · 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
Based on interview and record review, the facility failed to follow their policy and investigate an allegation of resident-to-resident physical abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3. The findings include:On March 13, 2026, at 3:00 PM, R2 was walking around at his bedside and the doorway of his room. R2 said he got into a fight with his roommate (R1) in the dining room on March 12, 2026. R2 said, he got in my face, and I pushed him. R2 said he pushed R1, and R1 fell out of his wheelchair and was able to get up on his own. On March 13, 2026, at 3:15 PM, R1 was in the day room in his wheelchair. R1 said he was in the dining room on March 12, 2026, around 7:00 AM, when R2 approached him and started yelling at him, and suddenly pushed him out of his wheelchair. R1 said it happened so fast, and there was another resident in the dining room, but he did not remember the resident. R1 said there were no staff present in the dining room with them, and no staff saw what happened. R1 said he felt bad that someone attacked him at his place 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 · Dcited before2026-02-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify law enforcement and the state surveying agency of the attempted diversion of narcotic medications. This applies to 2 of 2 residents (R7 and R8) reviewed for control of narcotic medications.The findings include: On 02/13/26 at 11:15 AM, V3 (Registered Nurse/RN) stated on 08/09/25 he left two bingo cards of Norco, one for R7 and one for R8 on top of the cabinet in the medication room. V3 stated he took a break and when he returned from break, the medications were not where he placed them. V3 stated only him and V4 (RN) had keys to the medication room. V3 stated he searched the medication room and found both of the bingo cards inside of V4's unzipped shoulder bag. V3 stated he contacted V2 (Director of Nursing/DON) and informed her of the situation. V3 stated V2 and V1 (Administrator) immediately came to the unit. On 02/14/26 at 1:44 PM, V2 stated on 08/09/25, she received a call from V3. V3 stated he had placed two narcotic medications (Norco) 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 · Dcited before2026-02-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to securely store controlled substances in the medication room. This applies to 2 of 2 residents (R7 and R8) reviewed for medication storage.The findings include:On 02/13/26 at 11:15 AM, V3 (Registered Nurse/RN) stated on 08/09/25 he left two bingo cards of Norco, one for R7 and one for R8 on top of the cabinet in the medication room. V3 stated he took a break and when he returned from break, the medications were not where he placed them. V3 stated only him and V4 (RN) had keys to the medication room. V3 stated he searched the medication room and found both of the bingo cards inside of V4's unzipped shoulder bag. V3 stated he contacted V2 (Director of Nursing/DON) and informed her of the situation. V3 stated V2 and V1 (Administrator) immediately came to the unit. On 02/14/26 at 1:44 PM, V2 stated on 08/09/25, she received a call from V3. V3 stated he had placed two narcotic medications (Norco) on the counter in the medication room that were due to be…
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 34 citations
- Potential for harm · Dcited before2026-02-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to follow their policy and report an allegation of abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3.The findings include:On February 17, 2026, at 9:43 AM, V1 (Administrator) I did do a reportable for [R1] in December (2025). He alleged to an insurance person that he was abused and stated that it was months ago, and he could not give a description of the individual. All he could say that it was a female and could not give a description or details of what exactly happened. This was investigated by (state surveying agency) with no findings. I also called the Insurance company who he reported this allegation to. The Social Service Director, a male, and his case manager, a female, spoke to him about it.R1's face sheet showed multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, unspecified Dementia, unspecified severity without behavioral disturbances, psychotic disturbance, mood disturbance and anxiety, cognitive communication deficit, major depressive disorder, recurrent,…
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 before2025-10-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of sexual abuse to the state surveying agency and the police within required timeframes. This applies to 1 of 3 residents (R1) reviewed for abuse allegations.The findings include:On 10/9/25 at 4:00 PM, R1 stated that on 9/28/25, V3 (Nurse) was applying cream to her buttocks during wound care and then V3 applied the cream to her vaginal area and labia. R1 said that she felt that it felt sexual and that the nurse was violating her. R1 said that she reported the incident to V10 (Psychiatric Rehabilitation Service Coordinator/PRSC) on 10/2/25.On 10/10/25 at 1:14 PM, V10 (PRSC) stated that on 10/2/25, R1 told her that V3 (Nurse) had provided wound care to R1. V10 stated R1 told her that V3 applied a cream on and around her wound and then to R1's genital area, where it should not have been put on. V10 said R1 told her that V3 then touched her genital areas. V10 said that R1 told her that it made her feel bad and that she had to clean 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 · Dcited before2025-10-17 · 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 follow their abuse policy by failing to timely investigate an allegation of abuse and suspend the alleged perpetrator. This applies to 1 resident (R1) reviewed for abuse allegations in a sample of 3.The findings include:On 10/9/25 at 4:00 PM, R1 stated that on 9/28/25, V3 (Nurse) was applying cream to her buttocks during wound care and then V3 applied the cream to her vaginal area and labia. R1 said that she felt that it felt sexual and that the nurse was violating her. R1 said that she reported the incident to V10 (Psychiatric Rehabilitation Service Coordinator/PRSC) on 10/2/25.R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of major depressive disorder, bipolar disorder, anxiety disorder, and suicidal ideations. R1's 8/15/25 MDS (Minimum Data Set) shows that R1's cognition is intact.On 10/10/25 at 1:14 PM, V10 (PRSC) stated that on 10/2/25, R1 told her that V3 (Nurse) had provided wound care to R1. V10 stated R1 told…
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 before2025-04-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to maintain the kitchen in a manner to prevent foodborne illness. This applies to 163 residents in the facility receiving dietary services. Findings include: On 04/15/25 09:56 AM, V2 (Director of Nursing) confirmed 162 residents were being served from dietary services on 04/15/25. 1. On 04/15/25 at 10:22 AM, V12 (Dietary Director) stated the dishwasher is High temp. The dishwasher disinfects by temperature and should reach 180 degrees Fahrenheit. The kitchen dishwasher was run. The wash gauge temperature reached 150 degrees. The rinse gauge temperature reached 160 degrees. The temperature test strip used reads pass when blue bar turns orange 160 degrees Fahrenheit. V12 stated the dishwasher gauges have not worked properly for some time over a year. They use the test strips to assure the temperature of the water. They don't write down the temperature from the gauges on the log, they save the test strips to the log. 2. On 04/17/25 at 11:49 PM, V16 (Cook) checked the holding temperature for the coleslaw cups. V16…
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 before2025-04-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 implement fall risk precautions for residents at risk for falls. This applies to 5 of 5 residents (R3, R15, R21, R48, and R117) reviewed for accidents and supervision in a sample of 32. The findings include: 1. On 4/15/25 at 2:09 PM, R21 was lying in bed. Upon entry, R21 tried to get out of bed and began slipping due to the mattress hanging off the mattress. R21's mattress was angled downward and appeared to be about 10 inches larger than the bed frame. R21 said he had fallen in the past because when he sat on the edge of the bed, he slid but never got hurt. R21 said he's been having this issue for months. On 4/16/25 at 1:08 PM, R21's mattress was the same and he continued to struggle to get out of bed. On 4/17/25 at 9:51 PM, R21 said he had been complaining about the mattress for a long time. R21 said he had slipped a bit yesterday while trying to get out of bed as the mattress slides down. R21's mattress was angled downward on the left…
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 before2025-04-18 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to safely store resident medications. This applies to 4 residents (R37, R61, R103, and R137) reviewed for medication storage in a sample of 32. Findings include: On 4/16/25 at 1:12 PM, while reconciling narcotics with V3 (Registered Nurse/RN), the following medications were found labeled from pharmacy refrigerated med, but were stored in the narcotic box in the nurse's medication cart, not refrigerated: 1. R37's 3 vials of Lorazepam 2 mg/mL (milligram per milliliter) for a total of 14.5 mLs remaining. R37's Face Sheet shows a primary diagnosis of Conversion Disorder with Seizures. R37's POS (Physician Order Sheet) shows an order dated 2/20/25 inject Lorazepam 1 mg intramuscularly (IM) every 6 hours as needed for acute seizure activity. R37's Controlled Drug Administration Record shows he last received IM Lorazepam on 3/11/25. R37's Care Plan last revised 1/17/25 states he has a history of seizure disorder, and interventions include give seizure medication as ordered by doctor and monitor side effects 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 · D2025-04-18 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview and record review, the facility failed to provide residents and/or their representatives written notification of the reason for transfer to the hospital. This applies to 3 of 3 residents (R57, R93, and R113) reviewed for discharge in a sample of 32. The findings include: 1. R113's Face Sheet showed R113 was admitted to the facility on [DATE]. R113 had multiple diagnoses which included psychosis, chronic diastolic (congestive) heart failure, paranoid schizophrenia, delusional disorders, auditory hallucinations, and visual hallucinations. R113's MDS (Minimum Data Set) dated 04/01/25 showed R113 was cognitively intact. R113's Progress Note dated 11/28/24 at 8:36 AM, showed Resident exhibiting heighten agitation, aggressive behavior this morning, reportedly struck a housekeeping staff member, as she was cleaning his room. Per doctor's orders, he is being sent to (Hospital) for evaluation/stabilization. Progress Note dated 12/20/24 at 5:00 PM, showed Resident roommate observed resident vomiting 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 · D2025-04-18 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide the resident and/or their representative of the facility's policy for bed hold in writing. This applies to 1 of 1 resident (R113) reviewed for discharge in a sample of 32. The findings include: R113's Face Sheet showed R113 was admitted to the facility on [DATE]. R113 had multiple diagnoses which included psychosis, chronic diastolic (congestive) heart failure, paranoid schizophrenia, delusional disorders, auditory hallucinations, and visual hallucinations. R113's MDS (Minimum Data Set) dated 04/01/25 showed R113 was cognitively intact. R113's Progress Note dated 12/20/24 at 5:00 PM, showed Resident roommate observed resident vomiting and came to the nurses' station to report it. He began to continue to have large amounts of coffee brown projectile emesis x 4. 911 was called at 7:23 PM. 911 arrived and assessed resident. He left the facility per stretcher in route to (Hospital). The EMR (Electronic Medical Record) contained no documentation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-18 · 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 provide services to prevent decline and decrease in ROM (Range of Motion). This applies to 1 of 3 residents (R107) reviewed for range of motion in a sample of 32. Findings include: R107 diagnoses include Parkinson's disease, anemia, slow transit constipation and osteoarthritis. R107's current plan of care states R107 has limited ROM in the upper and lower extremities related to Parkinson's disease. The goal set for R107 is an active ROM program where R107 will be able to tolerate 1 set of 5 repetitions of AAROM (Active Assisted Range of Motion) to all extremities with limited staff assist, 1 to 2 times daily through next review. No documentation of the ROM program being carried out was noted in R107's EMR (Electronic Medical Record). On 04/17/25 at 01:06 PM, V17 (Restorative Nurse) stated R107's last restorative assessment was done on 12/9/24. The restorative recommendations made for R107 were for active ROM and bed mobility. V17 stated there should have been documentation of R107's restorative assistance, but R107 was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide catheter care in a sanitary manner, failed to utilize an indwelling catheter securing device, and failed to keep the indwelling catheter bag off the floor. This applies to 2 of 2 residents (R65 and 123) reviewed for catheter care in a sample of 32. Findings include: 1. R123 has diagnosis that includes bipolar disorder, type 2 diabetes, tremor, and neuromuscular dysfunction of bladder. R123 has a care plan in place for urinary tract infection and antibiotic use. On 04/16/25 at 02:04 PM R123's urinary catheter care was performed by V15 (Certified Nursing Assistant/CNA), and positioning assistance was provided by V14 (CNA). Using a wash basin and two washcloths, V15 wiped the right side of the labia, folded the washcloth, and wiped the left side of the labia, and folded the washcloth then wiped the outside center of labia's four times with the same washcloth. V15 wet the washcloth in the wash basin. V15 then wiped the right side 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 · D2025-04-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents' medications were available for administration. This applies to 2 of 2 residents (R134, R101) reviewed for pharmacy services in a sample of 32. The findings include: 1. On April 15, 2025, at 11:51 AM, R134 said they ran out of her Tramadol pain medication. R134 said she needed the Tramadol twice a day. R134 said sometimes it took the facility days to get them the medication and she was told last night that they were on the last pill. R134 said she wished the facility ordered the medication before it was running out. R134 said she would normally have gone for a walk but because she had not gotten the medication, she was not going to be able to. R134 said it was a big deal that she had not gotten it this morning. On April 15, 2025, at 12:40 PM, V9 (Registered Nurse) said R134 ran out of the Tramadol. V9 stated she checked the medication cart, and it was not available. V9 said it was last given at 6:45 PM on April 14, 2025.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-12-10 · 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
Based on observation, interviews, and record review, the facility failed to adequately maintain an effective infection prevention and control program to help prevent and control the transmission of a highly contagious communicable disease, the norovirus. This failure has the potential to affect all 165 residents that currently reside at the facility. Findings include: On 12/10/2024 at 08:40 AM, surveyor entered the facility and did not observe any signs posted at the front doors or lobby area indicating current norovirus outbreak. Review of resident roster dated 12/10/2024 documented census of 165 residents and indicated residents highlighted in grey are on isolation. On 12/10/2024 at 09:15 AM, V1 (Administrator) said the facility has had a recent norovirus outbreak. V2 (Director of Nursing/DON) was also present during this interview and said she is currently overseeing infection preventionist duties including the current norovirus outbreak. V2 (DON) then said the outbreak is clearing up and that currently there was only one resident with watery stools reported yesterday…
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 before2024-10-21 · 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 interview and record review, the facility failed to follow their policy and insert an indwelling catheter utilizing the smallest size catheter as ordered by the physician. This applies to 1 of 3 resident (R1) reviewed for indwelling catheters in a sample of 8. Findings include: The Urology Progress Note dated 11/9/23 documents under Any new orders? Please place 14FR or 16FR foley catheter. The Urology Progress Note dated 05/30/2024 documents R1's diagnoses that includes Urinary Retention, Urethral Stricture and Urethral Erosion. During this visit R1's 16-gauge indwelling catheter was replaced with a specialized indwelling 16-gauge specialty catheter. A Progress Note for R1 dated 10/10/2024 at 09:00 PM documents Foley cath (catheter) found on bed. New 20FR 30ml balloon Foley inserted, clear yellow urine obtained. On 10/21/2024 at 10:41 AM V10 (Registered Nurse) stated I went into (R1's) room and saw he had pulled the catheter with the balloon intact. It was laying on the bed. I knew he needed the catheter replaced so I just grabbed one and put it in. There was no bleeding or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-29 · 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, record review and interview the facility failed to timely complete a physician order for an X-Ray for 1 of 4 residents (R1) reviewed for change in condition. Findings include: On 04/26/2024 at 11:45 AM R1 was in bed with a cast on her right foot. The Progress Note dated 04/13/2024 10:00 PM documents R1 had a witnessed fall 04/13/2024 at 8:00 PM in the bathroom. R1 stated, I'm alright, my knee just give up, I am not in pain. After an hour R1 complained of pain and swelling to her right ankle. The physician was contacted, and an x ray was ordered to be completed by the on-call X-Ray service. The Radiology Results Report dated 04/17/2024 at 12:00 AM documents R1 with an Oblique fracture of the distal fibula and a distal tip fracture of the medial malleolus with ongoing healing. On 04/26/2024 at 10:40 AM V12 (Quality Assurance Nurse) stated I should have been calling the X-ray company to see why there was the delay in them coming out. I realized (04/16/2024) after needing them for another resident that (R1's) X-ray still wasn't done. The Facility Agreement with 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 · E2024-03-28 · 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 assist residents identified as needing assistance with personal hygiene. This applies to 4 of 5 residents (R12, R46, R51 and R120) reviewed for ADLs (activities of daily living) in the sample of 34. The findings include: 1. R12 had multiple diagnoses including ataxia, COPD (chronic obstructive pulmonary disease) and history of traumatic brain injury, based on the face sheet. R12's quarterly MDS (minimum data set) dated March 15, 2024 showed that the resident was cognitively intact and required assistance from the staff with regards to personal hygiene, including shaving. On March 25, 2024 at 11:39 AM, R12 was observed with accumulation of long and thick facial hair. R12 stated that he needed an electric razor and staff assistance to shave his facial hair. On March 26, 2024 at 10:25 AM, R12 was standing in the front lobby. R12 was observed with accumulation of long and thick facial hair. R12 stated that he needed the staff's assistance…
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 before2024-03-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure that it was free of tripping hazard in a common area of the facility. This applies to 35 of 35 residents (R6, R12, R14, R15, R23, R27, R34, R37, R42, R50, R54, R55, R56, R57, R70, R74, R75, R78, R79, R82, R85, R88, R92, R94, R98, R101, R112, R114, R115, R143, R152, R156, R158, R162, and R164) reviewed for falls. The Findings Include: On March 26, 2024 at 12:05pm, there was a difference in height of 1½ inches between the concrete slab immediately outside the front door and the next slab, approximately 6 feet from the front door to the facility. All persons coming into the front door must navigate this uneven pathway. On March 26, 2024, R143 stated he tripped on the uneven concrete outside the front door to the facility on March 22, 2024 and on one time before. The most recent MDS (minimum data set) shows R143 to be cognitively intact and that R143 uses a walker for ambulation. Documentation provided by the facility shows R143 had at least 2 falls related to the uneven concrete in the front of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-28 · 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 follow physician's order for medication administration. There were 25 medication opportunities with 6 errors resulting to 24% medication error rate. This applies to 4 of 5 residents (R88, R110, R120 and R127) observed during medication administration in the sample of 34. The findings include: 1. Face sheet showed that R127 is 92 years-old who has multiple medical diagnoses which include Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, and Hypertension (HTN). R127's Annual MDS (Minimum Data Set) dated February 12, 2024, showed that R127 is alert and oriented. On March 26, 2024 at 10:31 AM, V15 (Registered Nurse) administered morning medications to R127. V15 administered Carvedilol 6.25 milligrams (mg) tablet, Vitamin D3 25 micrograms (mcg) tablet, and Eliquis 5 mg tablet. V15 stated that R127 was supposed to received Ventolin inhaler and Lisinopril 40 mg tablet, however, it was not available. On March 26, 2024 at 10:39 AM, R127 stated he was upset about not getting his medications in a timely…
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 before2024-03-28 · 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 ensure that the nutritive value was maintained during preparation of pureed diet. This applies to 10 of 10 residents (R56, R69, R71, R83, R100, R129, R131, R132, R133, R140) reviewed for pureed diet in the sample of 34. The findings include: On March 26, 2024 at 10:03 AM, the pureed lunch meal prep of Swedish meatballs, buttered noodles and carrots prepared by V7 (Cook) was observed in the facility's kitchen. V7 stated that she had about 12 residents on pureed consistency and was going to prepare 12 servings and a few extra. V7 was not following any recipes. V7 started with the carrots and placed cooked carrots that was into water to the blender. V7 stated that she used a quart of carrots and cooked it in a quart of water. The blender showed that the water just covered the cooked carrots. V7 then added another quart of hot water to the blender. The contents now showed to fill up to almost the top of the blender. When V7 pureed the mixture, the blended product resembled a thin soupy mixture of water and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-03-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve lunch meal as in accordance with their schedule meal service times. This applies to 4 of 4 residents (R93, R115, R124 and R156) review for mealtime preference in the sample of 34. The Findings Include: 1. R124 had multiple diagnoses including bipolar disorder, major depressive disorder and schizoaffective disorder, bipolar type, based on the face sheet. R124's quarterly MDS (minimum data set) dated 3/13/2024 showed that the resident was cognitively intact and required set up assistance with eating. On March 25, 2024 at 10:31 AM, R124 was in his room, alert, oriented and verbally responsive. R124 stated the facility's lunch service is slow and that he had to wait for a long time for his meals. On March 25, 2024 at 1:05 PM, R124 was served his lunch meal inside the main dining room. Resident ate independently with good appetite and had consumed 100% of his meal. On March 26, 2024 at 11:04 AM, R124 stated that it was common 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 · D2024-03-28 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 that a resident that was NPO (Nothing by Mouth) was not left in the dining room during meal service and failed to ensure that a resident was clothed adequately during dining. This applies to 2 of 4 (R52 and R64) residents reviewed for dignity in the sample of 34. The Findings Include: 1. R52's face sheet included diagnoses of gastrostomy, cognitive communication deficit, lack of coordination and anoxic brain damage. R52's admission MDS (minimum data set) showed that R52 was moderately impaired with cognition and required maximum assistance from the staff with mobility and transfers. On March 25, 2024 at 12:20 PM, R52 was seated in the dining room at a table with R18 who was eating her lunch. R52 was receiving tube feeding from a container that was hung on a pole and covered with a cloth. R52 was looking at R18's food and extending her arms towards it and saying no, no, no and mouthing other incoherent sounds. On March 25, 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 · D2024-03-28 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 a resident was safe to keep and administer his own medications. This applies to 1 of 5 residents (R127) reviewed for medication pass/administration in the sample of 34. The findings include: On March 26, 2024 at 10:31 AM, V15 (Registered Nurse) prepared and administered multiple medications to R127. During this observation, R127 was informed by V15 that his inhaler and Lisinopril (blood pressure medication) was not available at the facility. After taking his prepared medications from V15, R127 walked away and appeared to be upset. On March 26, 2024 at 10:39 AM, R127 stated that he was upset because he did not receive his inhaler and blood pressure medication. R127 opened his bedside drawer and took out a small plastic container. Inside the said plastic container were seven (7) unidentified tablets, not in its original packaging. The seven unidentified tablets/medications were all dry and intact. R127 asked the surveyor to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · 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 ensure that the urinary catheter tubing was off the floor. This applies to 1 of 2 residents (R107) reviewed for urinary catheter in the sample of 34. The findings include: R107's face sheet included diagnoses of obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms and dementia with other behavioral disturbance. R107's care plan revised on February 6, 2024 showed that the resident has urinary catheter related to obstructive uropathy. On March 25, 2024 at 10:14 AM, R107's urinary catheter bag was in a privacy bag under R107's wheelchair with the tubing lying on the floor. R107 was stepping on the tubing when he moved his wheelchair back and forth with his feet getting tangled in the tubing every now and then. On March 25, 2024 at 10:57 AM, V13 (Certified Nursing Assistant) was shown the same and V13 stated It shouldn't be on the floor. He should have a leg bag. It is not attached now. I got him up today. On March 27, 2024 at 11:29 AM, V2 (Director of Nursing) 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 · D2024-03-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify the diagnosis and specific behaviors for the use of antipsychotic medication. In addition, the facility also failed to attempt gradual dose reduction (GDR) for a resident on psychotropic medication. This applies to 2 of 5 residents (R73, R90) reviewed for psychotropic medications in the sample of 34. The findings include: Face sheet showed that R90 is 62 years-old who has multiple medical diagnoses which include major depressive disorder, generalized anxiety disorder, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. On March 25, 2024 at 10:00 AM, R90 was resting in bed. R90 was alert and oriented and somewhat sleepy. R90 appeared irritable but there was no aggressive behavior displayed. R90 did not display any auditory or visual hallucination and paranoia. There was no psychotic behavior displayed. On March 25, 2024, at 12:00 PM, R90 was sitting in his wheelchair inside the bedroom,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transcribe physician's order for an anticoagulant medication. This applies to 1 of 1 resident (R27) reviewed for anticoagulant medications in the sample of 34. The findings include: R27's EMR (Electronic Medical Record) showed R27 was admitted to the facility on [DATE], with multiple diagnoses myocardial infarction, nonrheumatic aortic valve insufficiency, presence of prosthetic heart valve, long term use of anticoagulants, and nicotine dependence. R27's MDS (Minimum Data Set) dated February 20, 2024, showed R27 was cognitively intact. R27's anticoagulant care plan dated September 8, 2023, showed, I am on long term use of anticoagulant therapy related to nonrheumatic aortic valve insufficiency status post prosthetic heart valve. The care plan continued to show multiple interventions dated November 29, 2023, including Labs as ordered. Report abnormal lab results to the physician. The care plan continued to show multiple interventions dated November 29,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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 nutritional supplements as ordered by the Physician. This applies to 3 of 3 residents (R11, R86 and R140) observed during dining in the sample of 34. The findings include: On March 25, 2024 starting at 11:30 AM, the tray line service was observed in the facility's kitchen with V8 and V9 (Dietary Aides) on the tray line. 1. On March 25, 2024 at 11:48 AM, during tray line, R11 was served mechanical soft diet with 2 glasses (8 ounces) of nectar thick liquid milk. R11's meal ticket showed to add health shake and cottage cheese and these items were not served on the tray. On March 25, 2024 at 12:48 PM, R11 received a room tray and did not receive a health shake nor cottage cheese. V13 (CNA/Certified Nursing Assistant) who served the meal tray to R11, stated that the kitchen sends what is listed on the meal ticket. R11's diet order on the POS (Physician Order Sheet) included: Continue with health shakes with lunch and supper. May substitute fortified pudding for health shakes. Add cottage cheese every meal.…
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 before2024-03-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence care and blood glucose level check. This applies to 3 of 34 residents (R38, R90, R105) reviewed for infection control in the sample of 34. The findings include: 1. On March 25, 2024 at 12:15 PM, V19 (Certified Nursing Assistant/CNA) rendered incontinence care to R105 who had a large loose bowel movement. V19 wiped R105 from front to back, placed new incontinence brief and pad, assisted to dress, and repositioned R105. V19 changed her gloves multiple times throughout the care without performing hand hygiene. 2. On March 26, 2024 at 11:08 AM, V20 (CNA) rendered incontinence care to R90 who was wet with urine. V20 used wet wash cloth and wiped R90 from front to back. V20 removed the soiled brief and incontinence cloth pad and applied the clean incontinence brief and pad. V20 completed the tasks while wearing the same soiled gloves. 3. On March 26, 2024, at 4:16 PM, V16 (Registered Nurse) checked…
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 before2023-11-21 · tag F0609 — failed to report abuse allegations — widespreadTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to immediately report to the abuse coordinator an allegation of physical abuse to a resident (R2). This has the potential to affect all residents in the facility. The findings include: The facility resident roster printed on 11/16/23 showed 167 residents reside in the facility. On 11/16/23 at 11:22 AM, V3 (Certified Nursing Assistant/CNA) stated she was working with V4 and V5 (CNAs) on the evening shift of 11/2/23. V3 said V4 asked her and V5 to help undress and toilet R2. V3 stated R2 is a dementia resident with known behaviors including resisting care. V3 said R2 was clutching her clothes when V5 suddenly began pulling R2's hair. V5 was punching and kicking at R2 repeatedly. V3 said it did not stop until V4 put himself between V5 and R2. V3 said the incident happened around 9 PM and she should have reported it right away. V3 said she was afraid of retaliation by V5, so she did not report it until the next morning around 6:30 AM. On 11/16/23 at 11:58 AM, V4 (CNA) said he was working with V3 and V5 on the evening of 11/2/23.…
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 before2023-01-20 · 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 observation, interview, and record review, the facility failed to ensure residents receive meals in a timely manner and at the required temperatures that affect palatability. This applies to R12, R76, R140, R144 and 73 of 78 residents reviewed for temperatures and timeliness of food delivery in the sample of 34 The findings include: 1. Facility Resident Census and Condition of Residents (Form CMS--Centers for Medicare and Medicaid Services--672), dated 1/18/23, documents the total census was 78 residents. V2 (DON-Director of Nursing) stated there were 5 residents with gastrostomy tube feeding. On 1/17/23 at 10:45 AM, V1 (Administrator) stated, The residents are not eating in the main dining rooms due to Covid outbreak status. Instead, we are having the residents eat in their rooms. On 1/18/23 at 2:00 PM, the food trays were delivered in an uncovered cart to East Unit. V5 (Dietary Manager) stated, We are running behind. This unit should have been served at 1:30pm. We are short staffed. I only have two dietary aides and one cook. Ideally, one more aide would be helpful. 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 · F2023-01-20 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement an effective pest control program to prevent house flies and gnats in resident rooms and facility hallways. This applies to all 154 residents residing in the facility. Findings include: On 1/17/23 at 12:02 PM, the surveyor observed room [ROOM NUMBER] with two large house flies chasing R59. R59 stated to the surveyor that those were so annoying. On 1/17/23 at 12:10 PM, house flies were observed in the hallway in front of room [ROOM NUMBER]. R25 in room [ROOM NUMBER] stated, Sometimes those follow me onto the toilet. On 01/19/23 at 10:01 AM, during wound care observation with V6 (nurse), observed gnats and house flies in room [ROOM NUMBER]. On 01/17/23 at 12:01 PM, a large gnat flew out of R12, R47, and R144's room when the door was opened. On 01/18/23 at 10:24 AM, while observing V11 passing residents medications, a large gnat was observed flying around the medication cart. On 1/18/23 at 10:30 AM, V4 (Maintenance Director)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-01-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe environment by failing to repair headboards and doors in residents rooms. This applies to 4 of 4 residents (R25, R69, R99, and R454) reviewed for safe environment. Findings include: On 1/17/23 at 12:41 PM, during wound care observation, the surveyor observed a loose and shaky headboard with R454. On 1/17/23 at 12:10 PM, the surveyor observed the room [ROOM NUMBER] (R25, R69, and R99) entry door with the bottom panel peeling off and protruding outward. On 1/18/23 at 10:30 AM, V4 (Maintenance Director) stated, I wasn't notified on room door bottom panel peeling off and on loose/shaky headboard for R454. There is a maintenance log available, and anybody can enter the maintenance issues. There was no entry in the logbook to alert me of the maintenance issues. On 1/19/23 at 10:50 AM, V4 added, We fixed the door panel yesterday, but it came off again. The protruding door panel and loose/shaky bed headboard can injure residents.…
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 · D2023-01-20 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, The facility failed to provide monthly drug regimen review for 1 resident (R11) out of 5 residents reviewed for unnecessary medications in a sample of 34. On 01/19/23 at 01:28 PM a record review of R11 showed that she is a [AGE] year old female with impaired cognition (12/5/22 Minimum Data Set), and diagnoses including delusional disorders, major depressive disorders, anxiety disorders, essential hypertension, arteriosclerotic heart disease, long term use of anticoagulants, personal history of diseases of the circulatory system, and dependence on supplemental oxygen. R11 review of medications included clonazepam 0.5 milligrams by mouth at bedtime for anxiety, Eliquis 5 milligrams by mouth two times a day for heart disease, lidocaine pain relief 4% patch one time a day for pain, meclizine HCL 25 milligrams one tablet by mouth two times a day for dizziness/vertigo, aspirin 81 milligrams by mouth one time a day, sertraline 100 milligrams one time a day for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, The facility failed to maintain infection control practices while providing care to 3 residents (R108, R454 and R126) who were reviewed for infection control in a sample of 34. 1. R454 is an [AGE] year-old female with severe cognitive impairment per MDS dated [DATE]. Record review on wound assessment dated [DATE] documented a stage 4 (4.14 x 2.82 x 1.2 centimeter) sacral wound. On 1/17/23 at 12:41 PM, the surveyor observed V3 (Registered Nurse) providing wound care to R454's sacral wound. V3 removed the soiled dressing with drainage, cleaned the wound with wound cleanser and patted the wound dry. V3 did not wash hands or sanitize his hands after removing the old dressing with drainage. V3 continued and irrigated the wound with a topical antiseptic solution (Dakin) and then applied calcium alginate to the wound bed and covered it with a foam dressing without changing gloves and washing his hands after removing the soiled old dressing. On 1/17/23 at 12:52 PM, V3…
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.
- No harm found · C2025-04-18 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain the minimum 12 hour per year competency training requirements of CNAs (Certified Nurse Assistants). This applies to all residents that receive care and assistance from CNAs. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 4/15/25 documents that the total census was 164 residents. On 4/18/25 at 3:30 PM, V1 (Administrator) said all 164 residents in the facility receive care from the CNAs. On 4/16/25, proof of CNA competency training hours was requested from V1 (Administrator) for CNAs V13, V20, V21, V22, and V23. On 4/17/25 at 12:16 PM, V1 said the facility recently switched their computer-based training company and she did not have access to the facility's prior computer-based training platform. V1 said she could only provide the total number of hours of in-services completed at the facility. The provided in-service hours of training showed V13 had 2 hours, V20 had 2.5 hours, V21 had 1.5 hours, V22 had 2…
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.
- No harm found · B2025-04-18 · 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 observation, interview, and record review, the facility failed to provide the grievance policy to residents. This applies to 4 of 4 residents (R83, R101, R134, and R130) reviewed for grievances in a sample of 32. The findings include: On April 17, 2025, at 10:32 AM, the Resident Meeting was held. R83, R101, R134, and R130 were present. R83 said the residents had been asking for copies of the grievance policy and information on how to file a grievance since November 2024. R83 said they had not seen the grievance policy yet. R83 said she was told if they have a grievance, to see a staff member. R83 said she invited V11 (Social Service Director) to come to the meeting to explain the grievance policy, but it was not discussed during the meeting. On April 17, 2025, at 1:38 PM, all the facility bulletin boards were reviewed, and none of the bulletin boards contained the grievance policy. On April 17, 2025, at 3:01 PM, V11 said the residents asked for the grievance policy during the resident council meeting and they asked the administrator for it. V11 said the administrator gave…
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
$293,067 in federal fines across 4 penalties.
- $21,453 — penalty dated 2025-02-14
- $30,664 — penalty dated 2024-09-09
- $101,742 — penalty dated 2023-11-21
- $139,208 — penalty dated 2023-09-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to APERION CARE — 33 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.9 | -0.9 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 3 of 5 | 3.3 | -0.3 vs chain |
The other 32 homes this chain runs (chain average 1.9★, 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 | Share | Since |
|---|---|---|---|---|
| THE RAJCHENBACH FAMILY TRUST | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 17% | since 09/01/2013 |
| FREDERICK S FRANKEL TRUST | Organization | DIRECT OWNERSHIP INTEREST | — | since 09/01/2013 |
| TUROFSKY, STEVEN | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2013 |
| FRANK, MARIA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2013 |
| JUDE, JODIE | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | — | since 09/01/2013 |
| ULBERT, LISA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2013 |
| APERION CARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/16/2025 |
| ALADIN, MUSTAFA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2013 |
| HARDAMAN, LISA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2013 |
| SPECTOR, JENNIFER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2013 |
| WILHELM, NAFTALI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2013 |
| BERKOWITZ, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 03/17/2026 |
| FRANKEL, FREDERICK | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/03/2025 |
| MEYSTEL, YOSEF | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 03/17/2026 |
| RAJCHENBACH, CHAIM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 03/17/2026 |
| RAJCHENBACH, MOSHE | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/03/2025 |
| 555 W KAHLER, LLC | Organization | ADP OF THE SNF | — | since 03/31/2025 |
| ACI EQUITIES, LLC | Organization | ADP OF THE SNF | — | since 09/01/2013 |
| APERION CONSULTING, LLC | Organization | ADP OF THE SNF | — | since 09/01/2013 |
| CURIS SERVICES LLC | Organization | ADP OF THE SNF | — | since 09/01/2013 |
| DAVID A. BERKOWITZ REVOCABLE TRUST | Organization | ADP OF THE SNF | — | since 09/01/2013 |
| DECLARATION OF TRUST OF YOSEF MEYSTEL | Organization | ADP OF THE SNF | — | since 09/01/2013 |
| LIPSHITZ, RITA | Individual | ADP OF THE SNF | — | since 09/01/2013 |
CMS files one row per role, so the 37 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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 145316. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-18, 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.