Bria Of Woodriver

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

43.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 106 beds and averages 79.2 residents a day — about 75% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.23 hrs/resident/day on weekends vs 4.12 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.73 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 78% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

65 citations, most serious first. The 28 most serious are shown; the remaining 37 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-01-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide supervision to prevent elopement for 2 out of 2 residents (R2, R4). This failure resulted in R2 eloping through the front entrance at 2:05 AM unsupervised and the facility being notified of his location 4.4 miles away at 10:52 AM. This failure resulted in R4 eloping from the front door and being found across a busy two-lane road that borders the front of the facility approximately 500 feet away from the entrance at 1:27 PM. The Immediate Jeopardy began on 11/22/25 at 2:05 AM when R2 eloped through the facility's front door, R2 was not reported missing until six hours later at approximately 8:00 AM and found at 10:52 AM about 4.4 miles away from the facility in R2's wheelchair. On 1/15/26 at 3:40 PM, V1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 1/16/26, but noncompliance remains at Level Two because additional…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited beforedisputed · IDR2025-11-20 · tag F0659 — isolated
  Provide care by qualified persons according to each resident's written plan of care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure staff were knowledgeable and competent to provide emergent tracheostomy reinsertion for 1 of 1 resident (R2) in the sample of 1. This failure resulted in R2 being transported via EMS (Emergency Medical Services) for reinsertion of a trach after dislodgement after nursing staff on duty failed to attempt to reinsert the trach because they weren't properly trained and didn't feel comfortable/confident in doing so. R2 remains in the Intensive Care Unit following trach reinsertion. This has the potential to affect current and new admissions that require tracheostomy care. This resulted in an Immediate Jeopardy which began on 11/2/2025 at approximately 2:30 AM when R2 was sent to the hospital for reinsertion of trach replacement. On 11/14/2025 at 11:00 AM V2, Director of Nurses/Administrator in Training (AIT) and V3, Assistant Director of Nurses (ADON) were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited beforedisputed · IDR2025-11-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide necessary emergent care and services for 1 of 1 resident (R2) with a tracheostomy in the sample of 1. This failure resulted in R2 being sent out urgently via EMS (Emergency Medical Services) for trach reinsertion after staff failed to attempt to reinsert R2's trach when it was found dislodged. R2 was admitted to the ICU (Intensive Care Unit) for respiratory distress. This has the potential to affect current and new admissions that require tracheostomy care.This Immediate Jeopardy began on 11/2/2025 at approximately 2:30 AM when R2 was sent to the hospital for reinsertion of trach replacement. On 11/14/2025 at 11:00 AM V2, Director of Nurses (DON)/Administrator in Training (AIT) and V3, Assistant Director of Nurses (ADON) were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review the Immediate Jeopardy was removed on 11/18/2025 at 3:05 PM but remains at Level Two because additional time is needed to evaluate…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-10-03 · tag F0659 — pattern
  Provide care by qualified persons according to each resident's written plan of care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure staff were educated and competent in providing the necessary care and services for tracheostomies for 4 of 4 residents (R2, R4, R5, R6) in the sample of 6. This failure resulted in R2, R4, R5, and R6 being sent out emergently for routine tracheostomy care. R2 was found unresponsive in the Facility and staff performed CPR that was not in accordance with professional standards using R2's primary airway because they did not know how to do so. R2 died in the Facility, and death certificate is pending.This Immediate Jeopardy began on [DATE] at approximately 10:44 PM when R5 was sent to the hospital for suctioning/removal of mucus plug and tracheostomy replacement. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 9:03 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2025-10-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the Facility failed to ensure nursing staff had the knowledge, skills, and necessary supplies to provide tracheostomy care for 5 of 5 residents (R1, R2, R4, R5, R6) reviewed for respiratory care in the sample of 6. This failure resulted in Cardiopulmonary Resuscitation (CPR) not being performed in accordance with professional standards on R1 and R2 and caused unnecessary emergency hospital transport for R4, R5 and R6. R1 and R2 died in the Facility, and death certificates are pending. This Immediate Jeopardy began on [DATE] at 10:44 PM when staff were unable to replace R5's tracheostomy and adequately suction R5 to ensure airway remains clear and patent. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 9:03 AM. The surveyor confirmed by record review, interview and observation that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-10-03 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 Cardiopulmonary Resuscitation (CPR) according to accepted professional standards for 2 of 2 residents (R2, R1) reviewed for CPR in the sample of 6. This failure resulted in R1 and R2 not receiving adequate respiratory ventilation when staff did not provide rescue breathing via R1 and R2's primary airway of tracheostomy. R1 and R2 both died while in the Facility, and death certificates are pending. This Immediate Jeopardy began on [DATE] at 6:40 PM when R1 was found unresponsive, and CPR was not performed in accordance with professional standards. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 11:37 AM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate implementation and effectiveness of the removal plan.Findings include:1-R1's Face Sheet documents R1 was admitted to the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-10-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure changes in condition were reported for timely assessment and intervention for 1 of 3 residents (R2) reviewed for change in condition in the sample of 6. This failure resulted in R2 showing a change in condition with dilated pupils, hand to touch cool body temperature and decreased baseline response to care on [DATE] when V11 and V12 were providing care to R2. V11 and V12 stated they did not inform R2's nurse of R2's changes. Approximately 15-20 minutes later, V12 returned to check on R2 and R2 was found unresponsive and Cardiopulmonary Resuscitation (CPR) was initiated. R2 died in the Facility, and death certificate is pending.This Immediate Jeopardy began on [DATE] at approximately 5:00 PM when R2 displayed changes from his baseline that were not reported to his nurse. V1 and V2 were notified of the Immediate Jeopardy on [DATE] at 2:12 PM. The surveyor confirmed by interview, observation, and record review Immediate Jeopardy was removed on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-05-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement effective fall interventions for 1 of 3 residents (R2) reviewed for accidents in the sample of 7. This failure resulted on R2 falling 4 times, requiring to be sent to the hospital and receiving a laceration to her head. This past non-compliance occurred from 3/11/2026- 3/20/2026. Findings include:R2's progress noted dated 3/9/2026 documents R2 was admitted to the facility from assisted living.R2's face sheet date 5/7/2026 documents a diagnosis in part of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting Right dominant side, cerebral infarction, muscle wasting and atrophy right and left lower leg, weakness, reduced mobility, and abnormalities of gait and mobility.R2's Fall risk assessment dated [DATE] documents a score of 12 (score of 10 or above indicates high risk for falls)R2's Fall risk assessment dated [DATE] documents a score of 26.R2's fall risk assessment dated [DATE] document a score of 20.R2's fall…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2026-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to initiate and implement progressive interventions to prevent falls for 3 of 10 residents (R2, R19, and R51) reviewed for falls in a sample of 41.Findings Include: 1)R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of reduced mobility, muscle weakness, difficulty in walking, dementia, abnormalities of gait and mobility, and repeated falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired, uses a wheelchair, needs substantial/maximal assistance with sitting to standing and chair/bed to chair transfers. R2's Care Plan Date Initiated 3/30/2025 documents Fall: R2 is at high risk for falls related to incontinence, weakness, history of fall, glaucoma, confusion, and use of psychotropic meds. Intervention Date Initiated 8/10/2025 documents out to er. Intervention Date Initiated 11/13/2025 documents brightly colored reminder on wheelchair to not stand up…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-02-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide catheter care, including irrigation, in 1 of 5 residents (R75) reviewed for bowel/bladder incontinence, catheter, and UTI (Urinary Tract Infection) in the sample of 41. This failure resulted in R75 being hospitalized for a UTI.Findings Include:On 2/5/26 at 1:43 PM, R75 was observed in his room with a suprapubic catheter draining clear tea colored urine. R75 stated he has a suprapubic catheter, he does not take care of it himself, the staff cleaned it two or more days ago and he has had a recent urine infection. On 2/10/26 at 12:25 PM, R75 stated he was sent to the hospital about a month ago because his catheter was clogged up and it had to be replaced. R75 stated the staff only clean his catheter site every 2-3 days. Catheter care was observed with V5, Wound Nurse, and R75 complained of penile pain and tenderness around the suprapubic catheter site. R75's Face Sheet, undated, documents R75 has the following diagnoses: UTI, Sepsis,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-05-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow written orders for wound care treatment for 1 out of 4 residents, (R2); reviewed for quality of care in a sample of 5. This failure resulted in R2 being admitted to the hospital with wounds declining. Findings include: R2's face sheet documented he was admitted to the facility on [DATE] and discharged on 5/2/25. R2's face sheet documented his diagnoses were, in part, burn of third degree of right foot, type two diabetes mellitus and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. R2's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact. R2's Care Plan dated 4/25/25 documented R2 was at risk for skin complications (entered on 5/4/25) with interventions, in part, to provide treatment as ordered (entered on 5/4/25). R2's discharge summary was faxed from hospital on 4/23/25 to the facility, it included his wound care orders. The discharge summary wound care orders documented the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-05-13 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow wound care orders for 1 out of 4 residents, (R2) reviewed for quality of care in a sample of 5. This failure resulted in R2's experiencing severe pain. Findings include: R2's face sheet documented he was admitted to the facility on [DATE] and discharged on 5/2/25. R2's face sheet documented his diagnoses were, in part, burn of third degree of right foot, type two diabetes mellitus and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. R2's Minimum Data Set (MDS) dated [DATE] documented he was cognitively intact. R2's Care Plan dated 4/25/25 documented R2 was at risk for skin complications (entered on 5/4/25) with interventions, in part, to provide treatment as ordered (entered on 5/4/25). R2's orders documented acetaminophen 650 mg (milligram) tablet to be started 4/23/25 as needed for pain/fever/headache and oxycodone 5 mg tablet to be started 4/23/25 as needed for pain. R2's Medication Administration…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-04 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed assess, monitor, and treat a change of condition for 1 of 4 resident (R6) reviewed for quality of care in the sample of 15. This failure resulted in a delay of treatment for a significant change in condition resulting in R6's hospitalization. Findings include: R6's Face Sheet, print date of 2/19/25, documents that R6 was admitted on [DATE] and has diagnoses of Alzheimer's Disease and Dementia. R6's Minimum Data Set, dated [DATE], documents that R6 is moderately cognitively impaired and is independent with eating. R6's Nurses Note, dated 1/13/25, documents, Resident returned to the facility via (hospital) ambulance accompanied by EMS (Emergency Medical Services). The resident is alert and denies pain. The resident was a total assist into her bed and is 1.5 L (liters) of oxygen per nasal canula. Call light is within her reach. The resident is on droplet / contact isolation for influenza. R6's Nurses Note, dated 1/14/25, documents, Resident refused to leave…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify, assess, and monitor pressure ulcers, and provide the Physician prescribed treatment for 4 of 5 residents (R1, R2, R4, R5) reviewed for pressure ulcers in the sample of 15. The failure resulted in R5 developing a pressure ulcer of unknown stage while at the facility, not receiving treatment for a pressure ulcer for 23 days at which time it was unstageable, and R4 developing 3 pressure ulcers while at the facility and a sacral pressure ulcer that became infected. Findings include: 1. R5's Face Sheet, print date of 2/20/25, documents R5 was admitted on [DATE] with diagnoses of Severe Protein Calorie Malnutrition, Delusional disorder, Schizophrenia, and Heart Failure. R5's Minimum Data Set (MDS), dated [DATE], documents R5 is moderately cognitively impaired, dependent on staff for dressing, toileting, and hygiene, frequently incontinent for urine and bowel, and R5 has 2 unstageable pressure ulcers. R5's Braden Scale for predicting…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent pressure ulcer development and failed to provide resident centered interventions, monitoring and orders for residents who were identified to be at risk for pressure ulcers and for residents with pressure ulcers for 2 of 3 residents (R1, R2) reviewed for skin impairment. This failure resulted in R1 acquiring an unstageable pressure ulcer to his/her left heel and stage 3 pressure ulcer to right buttock; R2 requiring debridement of an unstagable pressure ulcer during a hosptial stay to R2's coccyx. Findings include: 1. R1's face sheet with a print date of 10/21/2024 documented R1 has diagnoses of type 2 diabetes mellitus, sepsis, cognitive communication deficit, contracture of left knee, dementia, osteoarthritis, hypertension, and paroxysmal atrial fibrillation. R1's MDS (Minimum Data Set) dated 10/9/24 documented R1 has moderately impaired cognition. R1's MDS dated [DATE] documented R1 requires substantial to maximal assistance with…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent employee to resident abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4. This failure resulted in R2 being physically and mentally abused, causing her to feel scared and not safe in the facility. Findings include: On 6/14/24 at 6:10 AM, R2 was in her room, sitting up on the side of the bed, with purplish green bruising noted under both eyes and a bruise to her left forearm. R2 was tearful and stated that the bruising under her eyes was caused by a fall, she was feeling scared after what happened, and she was pulling a wet pad out from underneath her and when she went to put it on the floor she fell forward out of the bed. R2 stated prior to that she was sitting up in her wheelchair in her room and V12, LPN (Licensed Practical Nurse), wanted her to go to bed. R2 stated she was having pain in her feet, doesn't need much sleep and wasn't ready to go to bed. R2 stated V12 and an unknown female employee (later…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain orders to treat a new pressure ulcer, to prevent deterioration of the pressure ulcer, and failed to have appropriate interventions in place to prevent new pressure ulcers from developing and keep existing pressure ulcers from getting worse for 2 of 4 residents (R3 and R4) reviewed for pressure ulcers in the sample of 11. This failure resulted in R4 developing a Stage 4 Pressure Ulcer on his right buttock. Findings include: 1. On 2/22/24 at 9:15 AM V4 (Wound Nurse) provided pressure ulcer treatment to R4's Stage 4 pressure ulcer on his right buttock. V4 stated that the wound was just discovered on 2/20/24. She stated that she has ordered a cushion for his wheelchair (w/c), and he is on an air mattress. She stated R4's pressure ulcer is on the side affected by his stroke, and he cannot feel it and she think this contributed to his not being aware he was getting a sore and not letting anyone know about it. V4 unfastened R4's adult…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility to monitor and prevent weight loss for one of two residents (R48) reviewed for weight loss in the sample of 33. This failure resulted in R48 having a slow insidious weight loss from March 2023 through July 2023 and a 12% weight loss since January 2023. Findings include: R48's admission Record Sheet, printed on 8/1/23, documented R48 had diagnoses of Dysphagia following other Cerebrovascular Disease, Moderate Protein-calorie Malnutrition, Cerebral Infarction. R48's Care Plan initiated on 10/12/22, documented Tube feeding: Resident is a risk for complications of g-tube r/t dysphagia from CVA (stroke). R48's Care Plan Intervention, dated 10/19/22 documented monitor weights and labs as ordered and notify dr (doctor) of sig (significant) wt (weight) changes. R48's Electronic Health Record (EHR) documented R48 weighed 264.5 pounds (lbs.) on 11/25/22. R48's Physician Order, dated 12/15/22 documents Every shift Osmolite 1.2, 68ml (milliliter)/hr (hour). R48's EHR documented R48 weighed 255 pounds (lbs.) on 12/27/22, a 9 lb. weight loss in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-07-02 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse for 1 of 3 residents (R2) reviewed for abuse in a sample of 8. Findings include:1. R2's Care Plan, dated 3/5/2023, documents that ABUSE: At risk for abuse and neglect r/t (related to) psychotropic meds, behaviors toward staff, dx (diagnosis) schizophrenia.R2's Minimum Data Set, dated [DATE], documents that R2 is moderate cognitive impaired and requires assistance with Activities of Daily Living (ADL).R2's Other Report, dated 6/4/2026, documents that Nursing Description I, (V5), LPN (Licensed Practical Nurse), was doing medication administration when I witnessed (R3) (resident) walk pass another resident using wheeled walker, he stepped on the foot of (R2). (R2) began yelling and stating his foot had been stepped on. R2 is oriented to person, confused/forgetful and unable to give a description of event.R2's Nurses Notes, dated 6/9/2026 12:19 PM, documents that Note Text: New order rec'd per (V8), NP (Nurse Practitioner), for STAT 2-view…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-02-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 and prepared in a manner which prevents potential contamination. This has the potential to affect all 76 residents living in the facility. Findings include: Facility [NAME], [NAME] (35156) - Kitchen On 2/5/2026 at 8:14 AM, in the walk-in refrigerator there was large industrial mesh bag of onions (50 pounds) sitting directly on the floor. In the corner was a large box of pasteurized eggs sitting directly on the floor. The eggs were next to a box of cupcakes and in the middle was a large industrial box of raw meat (chicken or pork) thawing. On 2/5/2026 at 8:15 AM, in the walk-in refrigerator on the metal shelf was a large industrial bowl of greens that was not dated and or labeled. Next to the bowl of greens was a bag of mozzarella cheese half opened and not covered sealed or labeled. The cheese was being exposed to the air. On 2/5/2026 at 8:16 AM, in the walk-in refrigerator on the metal shelf was a box of raw chicken…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-13 · tag F0676 — failed to keep up residents' daily-living abilities — pattern
  Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure call lights were being answered in a timely manner for 6 of 14 residents (R16, R17, R43, R67, R69 and R81) reviewed for call lights in the sample of 41. Findings include: 1-R67's MDS dated [DATE] document R67 is cognitively intact for decision making of activities of daily living. R67 uses a wheelchair and needs substantial/maximal assistance- Helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. During the Group Meeting on 2/5/2026 at 1:30 PM, R67 stated there were issues and have been complaints about the call lights not being answered in a timely manner. This is being brought up constantly at the Resident Council Meeting and does not seem to be getting any better. We typically wait for call lights at least 30 minutes if not more. 2-R16's MDS dated 11/2025 document R16 is cognitively intact for decision making of activities of daily living. During the Group Meeting on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-13 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to properly label medications for an unknown number of residents due to medications not being labeled in a sample of 41.Findings include:On 02/05/2026 at 8:10 AM the 100 Hall Medication Cart was inspected with V8, Registered Nurse (RN). In the top right drawer of the medication cart, 2 Breztri Inhalers and 1 Airsupra Inhaler were observed with no resident name or date opened. 1 Breztri inhaler noted to have 1 inhalation left, 1 Breztri inhaler noted to have 8 inhalations left, and the Airsupra inhaler noted to have 10 inhalations left.On 2/5/2026 at 8:13 AM V8, RN, stated she did not know whose inhalers those were, and the inhalers looked like they have been used. V8 stated all inhalers should be labeled with a resident name and the date the inhaler was opened. V8 stated she is unsure who the inhalers belonged to and maybe the midnight nurse put them in the top drawer to figure out whose inhalers they were.On 2/13/2026 at 9:39 AM V2, Director of Nursing, stated she expects all medications including inhalers to be labeled with…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-13 · tag F0808 — failed to follow doctor-ordered diets — pattern
  Ensure 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide Ice Cream with meals as ordered for 5 of 5 residents (R6, R24, R74, and R81) reviewed for Nutrition in a sample of 41.Findings include:1.) R1's Face Sheet documents R1 was admitted to the facility on [DATE] and has a medical diagnosis of Dementia and Hypertension.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired and needs setup or clean-up assistance with eating.R1's Physician Order dated 1/9/2026 at 10:53 AM documents NAS (NO ADDED Salt) diet. Regular texture, THIN LIQUIDS consistency, Super cereal at breakfast with sugar. Vanilla ice cream at Lunch and dinner.R1's Meal Ticket dated 2/6/2026 documents Lunch Daily: VAN Ice Cream. Dinner DAILY: VAN Ice Cream.On 2/5/2026 at 1:00 PM R1 received her lunch tray which consisted of meatloaf, mashed potatoes and gravy, fruit, and cake. R1 did not receive her ice cream as ordered with her lunch tray.On 2/5/2026 at 1:10 PM R1 stated she did not receive…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-13 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to perform infection prevention practices during medication administration, including hand hygiene and cleansing of the glucometer to prevent infections in 5 of 9 residents (R16, R52, R69, R75, R49) reviewed for infection prevention and control in the sample of 41.Findings Include:On 2/5/26 at 8:18 AM, Medication administration was observed with V9 LPN (Licensed Practical Nurse), with R52, V9 donned gloves, completed an accu-check and removed her gloves. V9 did not perform hand hygiene before or after donning and removing the gloves and did not clean the glucometer after use. A On 2/5/26 at 8:38 AM, V9 performed an accu-check on R16 with the glucometer used on R52 that had not been cleaned after use. V9 did not perform hand hygiene before or after glove use and did not clean the glucometer after use. V9 then administered R16 her medications and did not perform hand hygiene. On 2/5/26 at 8:55AM, V9 then into R69's room, administered her medications and did not perform hand hygiene before or after administration.…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-13 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  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, observation, and record review the facility failed to implement care plan interventions following resident falls for 1 of 10 (R51) residents investigated for falls in a sample of 41.Findings include:R51's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R51's EMR dated 3/27/24 documents a diagnosis of Cerebral Infarction, unspecified.R51's EMR dated 2/28/25 documents a diagnosis of Difficulty in walking, not elsewhere classified.R51's EMR dated 6/17/25 documents a diagnosis of Repeated Falls.R51's MDS (Minimum Data Set) 12/5/25 documents a BIMS (Brief Interview for Mental Status) score of 14 out of 15. The MDS documents that the resident requires supervision or touching assistance for roll left and right. The MDS documents that the resident requires partial/moderate assistance for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R51's Care Plan dated 3/6/25 documents FALL:…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-13 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  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 record review and interview, the facility failed to evaluate and revise a resident's Care Plan with progressive interventions following falls for 3 of 10 residents (R2, R19, and R68) in a sample of 41.Findings Include:1.) R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of reduced mobility, muscle weakness, difficulty in walking, dementia, abnormalities of gait and mobility, and repeated falls. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired, uses a wheelchair, needs substantial/maximal assistance with sitting to standing and chair/bed to chair transfers. R2's Care Plan Date Initiated 3/30/2025 documents Fall: R2 is at high risk for falls related to incontinence, weakness, history of fall, glaucoma, confusion, and use of psychotropic meds. Intervention dated 8/10/2025 documents out to emergency room (er.) Intervention dated 11/13/2025 documents brightly colored reminder on wheelchair to not stand up without…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to change soiled bed linens for a dependent resident in 1 of 2 residents (R10), reviewed for ADL (Activities of Daily Living) care provided for dependent residents in the sample of 41.Findings Include:On 2/5/26 at 10:00 AM, R10 was observed in her room lying on her left side. R10 has contractures noted to the left hand, left wrist, left elbow, and left shoulder. R10 was not able to move her left upper or left lower extremities. R10 is able to move her right arm but isn't able to make significant movements or position herself in the bed. On 2/5/26 at 12:13 PM, R10 was observed in her room in bed on her left side. R10 stated they delivered her lunch tray; she ate but made a mess. R10 had a liquid reddish colored substance, on her pillow and incontinence pad that appeared to be from a red colored drink. Surveyor asked R10 if staff were going to come in and change her bedding and R10 stated they already did, R10 then touched the incontinence pad with her right hand and stated it's wet referring to the red staining.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to implement pressure relieving interventions for the prevention and treatment of pressure ulcers in 1 of 2 residents (R10) reviewed for treatment/services to prevent/heal pressure ulcers in the sample of 41.Findings Include:On 2/5/26 at 10:00 AM, R10 was observed in her room lying on her left side, a heel protector to the left foot, no pillow between her knees or under her heels and is very thin in appearance. R10 has contractures noted to the left hand, left wrist, left elbow, and left shoulder. R10 was not able to move her left upper or left lower extremities. R10 is able to move her right arm but isn't able to make significant movements or position herself in the bed. R10 stated she has several wounds that she had prior to admission to the facility. On 2/10/26 at 7:53 AM, R10 was observed in bed, on her back/left side, knees contracted up to her waist, nothing between her knees, ankles, nothing under her heels, the left ankle was touching the bed, and R10's pressure relieving boot was on the bed but 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$468,820 in federal fines across 6 penalties. 2 Medicare payment denials on record.

• $22,315 — penalty dated 2026-05-13
• $71,570 — penalty dated 2026-01-22
• $283,460 — penalty dated 2025-10-03
• $31,603 — penalty dated 2025-05-13
• $47,824 — penalty dated 2025-03-04
• $12,048 — penalty dated 2023-11-15
• Medicare payment denial — starting 2025-10-31 for 21 days
• Medicare payment denial — starting 2024-02-15 for 12 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BRIA HEALTH SERVICES — 10 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 →

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

CMS files one row per role, so the 16 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $252K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

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

What families pay in IL