Hillside Rehab & Care Center
1308 Game Farm Road, Yorkville, IL 60560 · For profit - Limited Liability company · 79 certified beds · (630) 553-5811 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2023
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $158,570 in federal fines (most recent 2026-01-08)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 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 | 34.9% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 6.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 1.3% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 36.2% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.6% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 5.2% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 38.4% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.5% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 91.5% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.8% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.5% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 6.1% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 59.3% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 33.9% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 20.5% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.23 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.93 | 2.22 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. 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.
55.6% 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 45 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 23 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 57% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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 | 55.6%CMS range 40.4–69.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.6–14.3 | 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 | 39.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 30.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 34.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 89.5% | 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 | 0.0% | 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 | 6.8%CMS range 3.5–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.23 | 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 79 beds and averages 51.0 residents a day — about 65% occupied, or roughly 28 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.77 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.66 hrs/resident/day on weekends vs 2.82 on weekdays — 5% thinner on weekends. RN hours go from 0.50 to 0.48 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% 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.
35 citations, most serious first. The 13 most serious are shown; the remaining 22 are one tap away and print in full.
- Immediate jeopardy · Kcited before2023-11-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a female resident was protected from another resident who has a known history of sexual abuse. This failure resulted in the resident entering the room of another female resident, then touching her breasts and face and kissing her. This applies to 1 of 4 residents (R1) reviewed for sexual abuse in a sample of 5. This has the potential to affect all 24 female residents (R1, R3-R25) residing in the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 10/31/23 at 4:00 AM when R2, who has a history of sexual abuse, entered R1's room and put his hands down her gown and touched her breasts. V1 (Administrator) was notified of the Immediate Jeopardy on 11/16/23 at 1:55 PM. Although the immediacy was removed on 11/17/23, the facility remains out of compliance at Severity Level II because additional time is needed to evaluate the implementation and effectiveness of the plan of correction, including…
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 before2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who were high risk for falls were supervised to prevent falls. These failures resulted in R1 & R3 falling being sent to the hospital and sustaining fractures. This applies to 2 of 3 residents (R1 & R3) reviewed for safety/supervision in the sample of 5. The findings include:1. R1's face sheet lists his diagnoses to include: congestive heart failure, shortness of breath, Type 2 diabetes mellitus, morbid obesity, anxiety disorder and wedge compression fracture of first lumber vertebra. On 1/7/26 at 9:57 AM, R1 was sitting in his wheelchair in his room. He stated, he had pain in his back. This surveyor asked him why what happened? He stated, he had a fall and hurt his back. He was going to the bathroom, and the CNA (V3 Certified Nursing Assistant) was on the phone. He told her he was done and ready to get up, she told him to wait because she was on the phone. He was sitting there for 25 minutes already and did not want 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.
- Actual harm · G2025-06-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the nurse practitioner's orders to consult a wound care doctor for treatment of a new acquired wound. The facility also failed to reposition a resident who was at risk for pressure ulcers. This applies to 2 of 3 residents (R1 and R8) reviewed for pressure ulcers in the sample of 8. This failure resulted in the R1's wounds declining, enlarging and developing into full thickness injuries. The findings include: 1. R1's electronic medical record showed R1 was originally admitted to the facility on [DATE]. R1's medical record also showed he was discharged to the hospital on May 21, 2025 and readmitted to the facility on [DATE]. R1's medical record showed R1 had medical diagnoses that included encephalopathy, malignant melanoma of the skin/shoulder, end stage renal disease, epilepsy, chronic congestive heart failure, and dementia. R1's Minimum Data Set, dated [DATE] showed that R1 required substantial/maximal assistance to reposition 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.
- Potential for harm · Ecited before2026-05-06 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow standard infection control practices related to hand hygiene during provisions of incontinence care and medication administration. The facility failed to ensure that staff wear complete PPE (Personal Protective Equipment) during care for a resident on EBP (Enhance Barrier Precaution). The facility also failed to ensure that soiled linens are in a linen bag while being transported to the soiled utility room, and a CPAP (Continuous Positive Airway Pressure) machine is stored in a hygienic way. This applies to 10 of 21 residents (R4, R13, R18, R20, R22, R23, R26, R36, R48, R62) reviewed for infection control in the sample of 21. The findings include: 1. On May 05, 2026, from 8:39 AM through 9:53 AM, V4 administered medications to different residents (R18, R23, R26, R62). These residents have different routes such as oral (R18, R23, R26), inhalers and eye drops (R18), and gastrostomy tube (R62). At 8:39 AM, V4 was observed preparing…
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 · D2026-05-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that a resident assessed to need assistance with all activities of daily living care needs had access to their call light to call for assistance. This applies to 1 of 3 residents (R4) reviewed for accommodation of needs in the sample of 21. The findings include:R4 is a [AGE] year-old with a diagnoses history of vascular dementia, heart failure, and partial paralysis following a stroke who was admitted to the facility January 30, 2024. On May 04, 2026 at 11:15 AM, R4 said he needed to go to the bathroom. R4 said he doesn't know where his call light is. R4's call light was sitting on the floor behind his bed wrapped around the frame. On May 04, 2026 at 11:34 AM, R4's call light remained on the floor behind his bed wrapped around the frame. R4 said he really needed to go to the bathroom. On May 05, 2026 at 9:40 AM, R4 said he needed to use the bathroom, he would use his call light to ask for assistance but he can't find it. R4's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-06 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that an adaptive device was in place according the physician order. This applies to 1 of 2 residents (R33) observed for range of motion in the sample of 21.The findings include:R33's electronic medical record (EMR) shows R33 has multiple medical diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R33's Physician Order Summary (POS) dated April 30, 2026, shows to apply a splint (carrot) to the left hand (orthosis) in affected extremities daily as tolerated. R33's Minimum Data Sheet (MDS) dated [DATE], showed R33 is alert and oriented. On May 4, 2026, at 10:45 AM, during facility's unit rounds with V13 (Certified Nursing Assistant/CNA), R33 was observed resting in bed. V13 said that R33 is alert and oriented and totally dependent on activities of daily living (ADL) care. R33's left arm and hand were noted with limited movement. R3's left hand and fingers were very stiff.…
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 before2026-05-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide incontinence care in a timely manner for residents who were identified as incontinent and failed to ensure the indwelling urinary catheter bag was always below the resident's bladder. This applies to 2 of 6 residents (R3, R9) reviewed for incontinence and catheter care in the sample of 21. The findings include:1. R3's electronic medical record (EMR) showed R3 had multiple diagnoses including type 2 diabetes mellitus with chronic kidney disease uncontrolled and congestive heart failure (CHF). R3's Physician Order Summary (POS) showed R1 was receiving Torsemide (diuretic or water pill) 20 milligrams (mg) twice a day for CHF. On May 4, 2026, at 10:43 AM, R3 was sitting in his wheelchair in his bedroom, R3 said he has heart failure and renal failure. According to V13 (Certified Nursing Assistants/CNA), R3 is alert and oriented and requires extensive assistance with activities of daily living (ADL) care. On May 5, 2026, at 12:35 PM, V11 and V13 (Both CNA) assisted R3 to the toilet. R3's incontinence brief…
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 · D2026-05-06 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement physician orders for IV PICC (intravenous peripherally inserted central catheter) line dressing change as needed, failed to have a care plan in place for management of care of IV site in order to prevent infection. This applies to 1 of 2 residents (R40) reviewed for IV therapy in the sample of 21. The findings include:R40's face sheet showed that R40 was admitted on [DATE], with multiple diagnoses including non-pressure chronic ulcer of right heel and midfoot with unspecified severity, pressure ulcer of unspecified site, urinary tract infection, pain, type 2 diabetes mellitus with foot ulcer, neuropathy. R40's admission MDS (minimum data set) dated February 18, 2026, showed that R40 was cognitively intact. R40's POS (Physician Order Summary) showed that R40 was initially (start date April 18, 2026) on IV antibiotic vancomycin in 0.9 sodium chloride solution; 1.5 gram/250 ml (milliliter) every 12 hours (8:00AM, 8:00PM) related 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 · D2026-05-06 · 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 safe storage of controlled medications. This applies to 2 of 2 residents (R6 and R18) reviewed for medication storage in the sample of 21. The findings include:R18's EMR (Electronic Medical Record) showed R18 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, spinal stenosis, low back pain, muscle spasms, pain unspecified, pain in right arm, and migraine. R18's Physician Order Report showed an order dated September 13, 2024, for hydrocodone-acetaminophen(Pain medication) 5-325 mg (milligrams) twice a day (7:00 AM to 11:00 AM, 4:00 PM to 7:00 PM). On May 6, 2026, at 12:12 PM, during the controlled substance count of the Wing 2 cart with V5 (Registered Nurse, RN), R18's blister punch card for hydrocodone-acetaminophen 5-325 mg had 20 tablets remaining. The back of the blister punch card on the compartment…
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 · D2026-05-06 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow physician order and failed to follow their policy and procedure with administering inhaler medication. There were 25 medication opportunities with 3 errors resulting in 12% medication error rate. This applies to 2 of 4 residents (R18, R62) reviewed for medication pass in the sample of 21. The findings include:1. On May 5, 2026, at 9:12 AM, V4 (Nurse) administered medications to R18 including Advair HFA oral inhaler and Incruse Ellipta inhaler. V4 handed the Advair inhaler to R18 without instructions R18 took 2 puffs of the Advair one after another, then V4 handed the Incruse Ellipta right after. R18 took a puff of the Incruse Ellipta within 5 seconds after the Advair. R18 Medication Administration record dated May 2026 showed an order of Advair HFA (Fluticasone Propion-Salmeterol) 230-21 mcg/actuation inhaler 1 puff once daily.Facility's Undated Policy and Procedure for Oral Inhalation Administration show:Purpose: To allow for safe, accurate, and effective administration of medication using an oral…
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 before2026-04-03 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure residents received their showers.This applies to 4 of 5 residents (R1, R3, R4 and R5) reviewed for bathing in a sample of 6 residents.Findings include:Findings include:1.On 04/01/26 at 11:27 AM, R3 stated he has not been getting his two showers a week and he wanted them. R3 stated his shower days are on Wednesday and Saturday. R3 stated there are only two staff that will shower him when requests to be showered. During the interview R3 had a foul body odor.The POC (Point of Care) documentation for R3 shows he had a total of four showers for the month of February 2026, and R3 did not receive a shower for six days from 2/12/26-2/17/26. R3's March 2026 POC documentation showed R3 was not showered from 3/08/26 to 3/15/26. R3's physician orders direct R3 to be showered twice weekly on Wednesday and Saturday evenings.2.On 04/01/26 at 10:42 AM, R4 stated he does not get showers he gets bed baths, but he did not have a preference. R4 did not recall when he was last bathed. During the interview R4 had a stale…
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 · D2025-06-18 · tag F0573 — isolatedLet each resident or the resident's legal representative access or purchase copies of all the resident's records.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident who requested medical records were provided the records in a timely manner. This applies to 1 of 2 resident's (R2) reviewed for medical records in the sample of 8. The findings include: R2's electronic medical record showed R2 was admitted to the facility on [DATE] with diagnoses that included myopathy, inflammatory and immune myopathies, pain in leg, anxiety, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and history of falling. On June 16, 2025 at 11:33 AM, R2 stated she asked V15 (Director of Rehab) several times to give her some therapy medical records. R2 stated, V15 said multiple times she would get the medical records for R2 but she still has not received the medical records she requested. On June 17, 2025 at 2:40 PM, V1 (Administrator) stated she received a written request for medical records from R2 on June 5, 2025. V1 stated that V10 (Business Office Manager) told V1 later that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-18 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's family/POA (Power of Attorney) of a new wound to the resident's sacrum. This applies to 1 of 4 residents (R1) reviewed for change of condition notification in the sample of 8. The findings include: R1's electronic medical record showed R1 was originally admitted to the facility on [DATE]. R1's medical record also showed he was discharged to the hospital on May 21, 2025 and returned to the facility on May 29, 2025. R1's medical record showed R1 had medical diagnoses that included encephalopathy, malignant melanoma of the skin/shoulder, end stage renal disease, epilepsy, chronic congestive heart failure, and dementia. R1's progress note dated June 2, 2025 written by V2 (Licensed Practical Nurse) showed the following: Resident is having skin breakdown on buttocks, redness, and open areas of about 0.1 x 0.1 centimeters. Cleaned with wound cleanser, used calcium alginate and covered it with a boarded gauze. On June 16, 2025 at 1:04 PM,…
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 22 citations
- Potential for harm · Dcited before2025-06-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly transfer a resident who required hands-on assistance to ascend stairs of a transport van. This applies to 1 of 3 residents (R2) reviewed for transfers in the sample of 8. The findings include: R2's electronic medical record showed R2 was admitted to the facility on [DATE] with diagnoses that included myopathy, inflammatory and immune myopathies, pain in leg, anxiety, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and history of falling. On June 16, 2025 at 11:33 AM, R2 was crying and stated V9 (Certified Nursing Assistant/CNA) came without a wheelchair to take her to a doctor's appointment. R2 stated she told V9 she could not walk that far to the van and he had to get a wheelchair. R2 stated V9 then returned with a wheelchair. R2 stated V9 wheeled her to the van, but could not put her in the back of the van where residents in wheelchairs normally sit because he said there was a bunch of equipment back…
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 · F2025-03-07 · 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 properly label/date/store food items, maintain proper levels for sanitation bucket, and wear hair restraint while preparing and serving food from facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 3/4/25 documents the total census was 45 residents. On 3/5/25 at 1:30 PM, V2 (DON-Director of Nursing) said there is only one resident on NPO (Nothing by Mouth); all other residents eat from the facility kitchen. On 3/4/25 starting at 9:53 AM, the facility kitchen was toured in the presence of V9 (Culinary Director), and the following was found: V9 and V15 (Cook) were not wearing hair covering. V15 was preparing food items for lunch. In the dry storage room, the following food items were found opened and undated: two bags of gravy mixes, one bag of panko , and one big jar of peanut butter.…
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 before2025-03-07 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to review and update the Infection Control Policy Annually, Implement a system of surveillance to identify infections or communicable diseases, appropriately handle and store linens, wear appropriate Personal Protective Equipment, prevent cross contamination during wound care and incontinence care, perform appropriate hand hygiene and implement Enhanced Barrier Precautions. This affects all 45 residents in the facility during the time of this survey. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 3/4/25 documents that the total census was 45 residents. On 3/5/25 at 12:02 PM, V2 (DON) provided the state surveyor the facility's current copy of their Infection Control policy with a date of August 2018. V2 and V18 (IP) both confirmed that it was the facility's current Infection Control policy. On 3/6/25 at 12:41 PM V2 said that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-03-07 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to provide hygiene and grooming care assistance to dependent residents. This applies to 4 of 4 residents (R8, R17, R21, R22) reviewed for ADL (Activities of Daily Living) in a sample of 16. Findings include: 1. On 03/04/25 at 11:07 AM, R17 was sleeping in bed lying on his right side facing the wall. R17's undergarment was exposed and was saturated. R17's top bed sheet and bottom bed pad and bed sheets were saturated with urine. On 03/04/25 at 11:09 AM, V11 CNA (Certified Nursing Assistant) was called in by surveyor to provide incontinence care assistance to R17. V11 stated he provided incontinence care at 6 AM. V11 stated he had not changed or provide incontinence care since 6 AM. On 03/06/25 at 11:42 AM, V2 DON (Director of Nursing) stated residents need to be checked every two hours and as needed. The expectation is for hourly rounding can be done by a nurse or CNA. Even if a resident is sleeping, staff should be checking them and providing…
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 before2025-03-07 · 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 interview and record review, the facility failed to obtain vital information regarding residents' pacemakers and implanted defibrillator and ensure that it was readily available in the resident's medical record. This applies to 3 out of 3 residents (R3, R27, R30) reviewed for pacemakers in a sample of 16. Findings include: 1. R3's face sheet documents an admission date of 7/12/2024. R3's face sheet documents the following diagnoses: atrial fibrillation, hypertension, and presence of automatic implantable cardiac defibrillator. R3's medical record was reviewed. There was no physician order documenting the defibrillator and how often it should be checked. There was nothing in the progress notes, admission assessment or care plans that document the manufacturer, model, and serial number of the defibrillator. It was also unknown as to when the defibrillator was last assessed. On 3/6/2025 at 2:44 PM, V2 (DON-Director of Nursing) said facility does not have a Policy on Pacemakers and Defibrillators. 2. R27's face sheet documents an admission date of 8/24/2024. R27's face sheet…
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 before2025-03-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders and apply restorative devices to prevent further worsening of contractures. This applies to 1 of 2 residents (R23) reviewed for restorative in a sample of 16. The findings include: On 3/4/25 at 10:55 AM, R23 was sleeping. Both of her hands were severely contacted. She had no assistive restorative devices on her hands. On 3/5/25 at 12:30 PM, surveyor went with V8 (RN-Registered Nurse) inside R23's room. R23 is nonverbal. R23 still did not have any splint, carrot or other assistive device in both of her hands. Surveyor asked V8 where they were. V8 stated, I don't know. They should be here. She used to have a carrot but, it's soiled. V8 looked around and found one of the rolled up towels under the bed. She put the rolled up towel into the left contracted hand. She stated she will make another one for R23's right hand. On 3/5/25 at 1:10 PM, V1 (Administrator) said, (V7-Former RN) was our MDS (Minimum Data Set) nurse…
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 before2025-03-07 · 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 proper positioning of indwelling catheters. This applies to 1 of 3 residents (R33) who were reviewed for catheter care in a sample of 16. The findings include: On 03/04/25 at 12:40 PM, R33 was observed in his bed with an indwelling catheter leg bag on his right leg. R33 said that he wears his leg bag all day, every day, including when he is in the bed during the day. R33 said that the staff only puts the large drainage bag on at night before he goes to bed for the night. On 03/05/25 at 09:59 AM, V2 DON (Director of Nursing) said that R33 should not have the leg bag on when in bed. V2 said that the catheter bag should be lower than the level of the bladder to prevent back flow into the bladder, UTIs (Urinary tract infections,) and improper drainage. R33's diagnoses include history of UTIs, and benign prosthetic hyperplasia with lower urinary tract symptoms. R33's 9/4/24 care plan showed that R33 is at risk for UTIs due to catheterization secondary to a diagnosis of urinary retention with approaches…
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 · D2025-03-07 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to follow current standards for checking proper placement when administering medications through a g-tube (gastrostomy). This applies to 1 of 1 resident (R23) reviewed for g-tubes in a sample of 16. The findings include: On 3/5/25 At 12:58 PM, V8 (RN-Registered Nurse) wiped port of g-tube with alcohol pad. She checked for placement by instilling about 10 cc of air and then auscultated with her stethoscope. Surveyor asked V8 how she checks for placement. V8 said, I check for placement by instilling air and auscultating by listening with my stethoscope. Surveyor asked her if she ever checks for residual. She said, In the morning, I checked for residual. V8 administered three medications of Keppra, Claritin, and Miralax via g-tube to R23. On 3/6/25 at 9:42 AM, V2 (DON-Director of Nursing) stated, I think the regulation says the proper way to check for g-tube placement is by checking for residual. You probably shouldn't check placement by putting air into the g tube and listening. The nurse should follow what 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 · D2025-03-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observation, interview, and record review, the facility failed to contain and secure respiratory equipment. This applies to 4 of 4 residents (R29, R30, R32, R41) reviewed for oxygen equipment in sample of 16. The findings include: 1. On 3/4/25 at 10:38 AM, R32's nebulizer mask on her dresser was not covered. R32 stated it's never kept in a bag. R32's face sheet shows the following diagnoses: COPD (Chronic Obstructive Pulmonary Disease), Unspecified bacterial pneumonia, respiratory syncytial virus, and nasal congestion. R32's POS (Physician Order Sheet) shows an order for Ipratropium-albuterol solution for nebulization; 0.5 MG (Milligrams)-3 MG (2.5 MG base)/ 3 ML (Milliliters) every 4 hours as needed for congestion for SOB (Shortness of Breath) R32's MDS (Minimum Data Set) dated 2/28/25 shows a BIMS (Brief Interview for Mental Status) score of 3, which means she is severely cognitively impaired. 2. On 3/4/25 at 11:38 AM, R30's nebulizer mask was on his dresser and was not covered. R30 stated his nurse…
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 · D2025-03-07 · 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
Based on observation, interview, and record review the facility failed to properly secure medications. This applies to three out of three residents (R2, R3, R20) reviewed for medications in a sample of 16. The findings include: 1. On 3/4/2025 at 11:20 AM, a bottle of Preservision AREDS 2, 1 bottle of Nasal Mist, 1 bottle of ABC Plus Senior Multivitamin, and 1 bottle of Magnesium with Zinc was observed on R3's bed side table and nightstand. R3 said her friend brought the medications in a long time ago. She said she has all the medications on her table for some time and does not seem to bother the nurses. On 3/4/2025 at 11:24 AM, this surveyor and V8 (RN-Registered Nurse) reviewed R3's medication list. R3 has no order for medication to stay at the bedside, no order for R3 to self-medicate and had no order for Preservision AREDS 2, Nasal Mist, ABC Plus Senior Multivitamin, and Magnesium with Zinc. V8 said R3 did not trust staff to administer medication to her and wanted to keep the medication at the bedside. On 3/6/2025 at 9:30 AM, V2 (DON-Director of Nursing) said no resident is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-24 · 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, interviews and record review, the facility failed to follow physician orders to hold a blood thinner before a scheduled procedure, resulting in the procedure being re-scheduled. This applies to 1 of 4 residents (R1) reviewed for quality of care. Findings include: Review of R1's face sheet showed she last admitted to facility on 05/24/2024 and has a past medical history not limited to: chronic congestive heart failure, bariatric surgery status, open wound of abdominal wall, morbid (severe) obesity due to excess calories, chronic kidney disease (stage 3), major depressive disorder, peripheral vascular disease, lymphedema, body mass index 70 or greater, type 2 diabetes mellitus, hypertension, cellulitis, hypokalemia, streptococcal sepsis, and respiratory failure. Review of R1's Brief Interview for Mental Status (BIMS) score dated 09/27/2024 documented score of 15/15 that indicated no cognitive impairment. On 11/23/2024 at 10:24 AM, R1 said over the past weekend, nurses attempted to administer two injectable medications that she knew were on hold for an upcoming…
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 · E2024-04-18 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
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 the quarterly MDS (Minimum Data Set) assessments were completed in the required time. This applies to 5 of 5 residents (R14, R20, R21, R34, R39) reviewed in the sample of 14. The findings included: 1. R14's EMR (Electronic Medical Record) showed R14 was admitted to the facility on [DATE]. R14's MDS (Minimum Data Set) showed her ARD (Assessment Reference Date) was March 1, 2024. R14's quarterly MDS was transmitted on April 12, 2024, making it 132 days late. 2. R20's EMR showed R20 was admitted to the facility on [DATE]. R20's MDS showed her ARD was March 13, 2024. R20's MDS was transmitted on April 15, 2024, making it 123 days late. 3. R21's EMR showed R21 was admitted to the facility on [DATE]. R21's MDS showed his ARD was February 22, 2024. R21's quarterly MDS was transmitted on April 12, 2024, making it 140 days late. 4. R34's EMR showed R34 was admitted to the facility on [DATE]. R34's MDS showed his ARD was March 11, 2024. R34's quarterly…
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 before2024-04-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide peri-care in a manner that would prevent urinary tract infection (UTI). The facility also failed to ensure that an indwelling urinary catheter was secured to the resident who was wearing it. This applies to 6 of 7 residents (R1, R9, R14, R26, R30, R38) reviewed for perineum and catheter care in the sample of 14. The findings include: 1. Face sheet shows that R26 is 67 years-old who has multiple medical diagnoses which include, irritable bowel syndrome, end stage renal disease and urinary tract infection (UTI). Minimum Data Set (MDS) dated [DATE], shows that R26 requires extensive assistance for toileting care. On April 16, 2024, at 9:44 AM, V14 (Certified Nursing Assistant/CNA) rendered incontinence care to R26 who was wet with urine. V14 cleaned R26 with a wet washcloth from front to back. V14 cleaned the pubic area, however, she did not separate the labia to clean its inner corners and the urethra. V14 proceeded to wipe the back…
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 before2024-04-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of perineum and catheter care. This applies to 5 of the 14 residents (R1, R9, R14, R26, R30) reviewed for infection control in the sample of 14. The findings include: 1. On April 16, 2024, at 9:44 AM, V14 (Certified Nursing Assistant/CNA) rendered incontinence care to R26 who was wet with urine. V14 wiped R26 from front to back using a wet towel and a peri-care cleansing spray. After V14 wiped the back peri-area, V14 changed gloves without hand hygiene, she applied barrier cream, clean incontinence brief, and she assisted to dressed R26. V14 removed her gloves and left the room to get the mechanical lift for transfer. V14 completed the care without hand hygiene and without sanitizing the peri-care cleansing spray after she used it. On April 16, 2024, at 10:01 AM, V14 and V15 (CNA) transferred R26 from bed to wheelchair via mechanical…
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 before2024-04-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to notify the physician of new skin wound, obtain orders for treatment, and update the care plan. This applies to 1 of 1 residents (R34) reviewed for skin assessment in the sample of 14. The findings include: R34 is an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that include cerebrovascular disease, vascular dementia, atrial fibrillation, and anxiety. Per the MDS (Minimum Data Set) Assessment of March 11, 2024, R34 is severely cognitively impaired and requires substantial to maximal assistance with bed mobility and movement. On April 15, 2024, 11:47 AM, R34 was sleeping with left arm side against his left bed rail. On, April 16, 2024, at 9:00 AM, R34 was observed with V7 (Hospice Certified Nurse Aide). R34 was lying in bed wearing only an incontinence brief and was noted with a bruise to his forearm (lower left arm), and a deep red, open, and bleeding wound to his upper left arm. V7 stated that there was no dressing…
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 before2024-04-18 · 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 observation, interview and record review the facility failed to assess and provide proper adaptive device to resident, to prevent further reduction in ROM (range of motion). This applies to 1 of 2 residents (R30) reviewed for range of motions in the sample of 14. The findings include: R30 is 50 years-old who has multiple medical diagnoses which include non-traumatic intracerebral hemorrhage, multiple localized, altered mental status, cognitive communication deficit, lack of coordination, and aphasia. R30's MDS (minimum data set) dated February 19, 2024, showed that the resident was severely impaired with cognition. R30's MDS showed that she has functional limitation in ROM on both side of both upper and lower extremities. The same MDS showed that R30 required maximum to total assistance from the staff with most of her ADLs (activities of daily living). R30 was observed multiple times from April 15, 2024, through April 17, 2024 and during these observations, R30 was observed in bed with both hands tightly clenched. Hand rolls were noted lying on each side of her arms, but…
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 · D2024-04-18 · 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 document the reason for the use of an antipsychotic medication and develop interventions for dose reduction for this medication. This applies to 1 of 5 residents (R38) reviewed for unnecessary medications in the sample of 14. The findings include: Face sheet shows that R38 is 76 years-old who has multiple medical diagnoses which include unspecified psychosis not due to substance or known physiological condition, and depression unspecified. R38 was admitted from home on February 24, 2024. R38's Census record shows that R38 was initially admitted to the facility on [DATE], for a short-term rehab and was discharged home on May 23, 2023. R38 was re-admitted to the facility on [DATE]. On April 17, 2024, at 1:29 PM, V1 (Administrator) stated that R38 was re-admitted to the facility for a long-term care because her husband could not take care of her anymore. On April 16, 2024, at 3:25 PM, R38 was resting on her recliner. R38 was alert 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 · D2024-04-18 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow recipe for butternut squash during pureed meal preparation. This applies to 2 of 2 residents (R14 and R34) reviewed for pureed diets in the sample of 14. The findings include: On April 15, 2024 at 11:08 AM, V4 (Dietary Manager) stated that the facility currently only have R14 and R34 on pureed diets. On April 15, 2024, at 11:09 AM, the pureed lunch meal prep of Roasted Squash Butternut by V5 (Cook) was observed in the facility kitchen. V5 had a recipe in front of him that showed serving portion for one serving and V5 stated that he is preparing for 2 residents. V5 measured two #8 scoops (4 ounce/scoop) of cooked butternut squash into a blender and added three ladles (2 ounce/ladle) of broth into the same blender and pureed the mixture. This showed that V5 used total of 6 oz of broth to prepare 2 servings of roasted butternut squash. When V5 opened the lid of the blender the product appeared to be a watery loose consistency. V5 added 1 tablespoon of thickener to this mixture and blended it again to form…
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 · D2024-04-18 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to serve pureed braised beef in desired consistency for pureed diets. This applies to 2 of 2 residents (R14 and R34) reviewed for pureed diets in the sample of 14. The findings include: On April 15, 2024 at 11:08 AM, V4 (Dietary Manager) stated that the facility currently only have R14 and R34 on pureed diets. On April 15, 2024 at 11:13 AM, the pureed lunch meal prep of Braised Beef done by V5 (Cook) was observed in the facility kitchen. V5 stated that he is preparing the pureed beef for two residents. V5 placed two 6 oz/ounce scoops of cooked braised beef into the blender along with 1 oz of beef broth and pureed the mixture for about a minute. V5 opened the container and stated that the mixture was ready to be served. The pureed product had shreds of beef at the side of the blender and the contents of the blender appeared granular. V4, who was in the vicinity, was seen scraping down the shreds of beef from the sides of the blender into the pureed mixture before platting it into bowls. When taste tested, 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 · D2024-02-10 · 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 administer her IV (Intravenous) antibiotic as ordered by the physician. This applies to 1 of 3 residents (R1) reviewed for IV antibiotic use in the sample of 3. The findings included: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the left breast, chronic obstructive pulmonary disease, conversion disorder with seizures, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes, repeated falls, and ESBL (Extended Spectrum Beta Lactamase) in the blood and urine. R1 tested positive for Covid-19 on February 8, 2024. R1's MDS (Minimum Data Set) dated January 26, 2024, showed that R1 had moderately impaired cognition. R1's POS (Physician Order Set) showed Ertapenem 1 gram once a day (7:00 AM - 11:00 AM) for ESBL (Extended Spectrum Beta Lactamase). R1's progress notes were reviewed and showed the chest wall medication port needle had come out of R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-17 · 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 observation, interview, and record review, the facility failed to report an alleged abuse incident. This applies to 1 of 4 (R1) residents reviewed for abuse allegation reporting in a sample of 5. The findings include: R1's face sheet showed that R1 was admitted to the facility on [DATE] and had diagnoses of cerebral infarction, occlusion, and stenosis of the left carotid artery, depression, acute respiratory failure, and cognitive communication deficit. R1's 8/08/2023 MDS (Minimum Date Set) showed that her cognition was intact, and she needs extensive assistance with two or more staff for bed mobility, transfers, toileting, and personal hygiene. On 11/14/2023 at 9:43 AM, R1 was in bed watching television. The back of the head of R1's bed, is perpendicular to the doorway to her room, and it is immediately to the right of the doorway. R1 is unable to see anyone entering her room from the hall when she is in the bed. R1 said two weeks ago, R2 came to her room around 3:00 AM stood behind her and asked her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-06 · 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
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 sexual, verbal, and physical abuse for 4 of 4 residents (R1, R2, R4, R5) reviewed for abuse in the sample of 13. The findings include: 1. R2's face sheet shows she was originally admitted to the facility on [DATE] with multiple diagnoses including nontraumatic intracerebral hemorrhage, altered mental status and aphasia (inability to communicate). R2's 7/28/23 MDS (Minimum Data Set) assessment documents R2 to have severe cognitive impairment. The same assessment shows she requires extensive assist of 2 staff, and dependent for all care. She has impairment to both upper and lower extremities. On 11/4/23 at 9:30 AM, R2 was observed lying in bed with the head of the bed elevated. She was alert and unable to speak. R2 was wearing a clean gown and had a sheet covering her. A sign on her door indicated a camera was always in use, and it was observed on top of the closet directed towards R2's bed. On 11/4/23 at 10:00…
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
$158,570 in federal fines across 3 penalties. 1 Medicare payment denial on record.
- $27,370 — penalty dated 2026-01-08
- $11,960 — penalty dated 2025-03-25
- $119,240 — penalty dated 2023-11-06
- Medicare payment denial — starting 2025-06-25 for 11 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 HELIA HEALTHCARE — 13 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 | 2 of 5 | 2.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 2 of 5 | 1.3 | +0.7 vs chain |
| Quality measures | 1 of 5 | 2.7 | -1.7 vs chain |
The other 12 homes this chain runs (chain average 2.2★, 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 |
|---|---|---|---|---|
| MILLER, STEPHEN | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE | 100% | since 02/01/2009 |
| MUELLER, NATALIE | Individual | W-2 MANAGING EMPLOYEE | — | since 03/01/2020 |
| MILLS, MICHAEL | Individual | CORPORATE OFFICER | — | since 01/01/2017 |
| BRIDGEMARK HEALTHCARE, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2003 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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 $232K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145609. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-06, 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.