The McKendree Post Acute & Rehabilitation

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

50.8% 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 140 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.3% 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 95 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 0.35 therapist hours per resident per day in 2026Q1 — more than 60% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 180 beds and averages 173.3 residents a day — about 96% occupied, or roughly 7 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.95 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 3.09 hrs/resident/day on weekends vs 3.66 on weekdays — 16% thinner on weekends. RN hours go from 0.62 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above the national median of 45%.

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

Inspection trend

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

37 citations, most serious first. The 14 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · K2023-10-03 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  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 policy review, medical record review, observation and interview, the facility failed to ensure a safe environment that prevented an incident of entrapment for 1 (Resident #145) of 77 sampled residents reviewed for assist bar use. The facility's failure to ensure a safe environment resulted in Immediate Jeopardy (IJ-a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #145, a vulnerable resident assessed to be cognitively impaired, became entrapped between the assist bar and mattress. The facility also failed to try an appropriate alternative prior to installing an assist bar, failed to perform side rail assessments and failed to obtain informed consent prior to installation of the assist bars for Resident #1, #3, #5, #8, #13, #14, #20, #23, #25, #26, #27, #28, #31, #33, #36, #38, #39, #41, #42, #43, #44, #45, #46, #50, #51, #52, #54, #56, #57, #58, #60,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-10-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility investigation, medical record review, and interview, the facility failed to prevent nonconsensual sexual contact between Resident #200 and 3 residents (Resident #8, #112, and #126). On 8/16/2023, Certified Nursing Assistant (CNA) #12 observed Resident #200 standing over Resident #126 pulling down his brief and Resident #126 was resisting the actions. CNA #12 left Resident #200 and Resident #126 alone in the room to get assistance in removing Resident #200 from the room. CNA #12 failed to protect Resident #126 from further potential nonconsensual sexual contact with Resident #200. Nursing staff failed to provide interventions and within 4 hours, Resident #200 was observed touching Resident #112's genital area while sitting in the 2 East common area. Nursing staff failed again to intervene appropriately and within 2 hours, Resident #200 had nonconsensual sexual contact with Resident #8 when she grabbed him and gave him an open mouth kiss then began licking his face. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-10-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, website www.localconditions.com review, medical record review, facility document review, observation, and interview, the facility failed to provide adequate supervision to prevent an avoidable accident for 2 (Residents #200, and #201) of 22 residents reviewed. Resident #200 and #201 moved from a safe environment to an unsafe environment when Resident #201 exited the building unsupervised, on 8/12/2023, and Resident #200 exited the building unsupervised, on 8/13/2023. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility also failed to accurately assess 22 (Resident #11, #22, #29, #31, #45, #53, #72, #73, #74, #76, #90, #91, #110, #112, #114, #118, #135, #140, #144, #200, #201, and #250) sampled residents reviewed for wandering/elopement…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-10-03 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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 facility policy review, medical record review, facility document review, and interview, the facility failed to provide nursing staff with the appropriate competencies and skill sets to assure resident safety and physical well being for 1 (Resident #361) of 17 sampled residents reviewed for falls. Resident #361 with a pain level of 10 (highest level of pain expressed) and unable to move her left leg was transferred by the Director of Nursing (DON) from the floor to a sitting position in a wheelchair. The facility's failure to ensure safety for Resident #361 after an accident resulted in a harm when Resident #361 screamed in pain when she was transferred to the wheelchair by the DON Review of the facility's policy titled, Fall-Clinical Protocol, dated 3/29/2017, revealed, .In addition, the nurse shall assess and document/report issues with the following .Recent injury especially fracture or head injury .Pain . Review of the medical record revealed Resident #361 was admitted to the facility on [DATE] with…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-20 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide 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 facility policy review, medical record review, Delivery Manifest Report Details, and interview, the facility failed to provide admission medication according to physician's orders and per facility policy for 1 of 3 (Residents #2) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, .Automated Dispensing Machine for First Dose and Emergency Medications, dated 1/2025, revealed, .The facility may use automated dispensing machines.for first dose and emergency medications.authorized personnel who have received training, have access to medications.the director of nursing or designee authorizes staff and administers user names and passwords for access to the dispensing machine.Upon receipt of a new medication order, facility staff should obtain the total number of doses necessary to cover the period of time from the administration of the first dose until it is expected to become available from the pharmacy. Review of the medical record revealed Resident #2 was admitted 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2023-10-03 · tag F0569 — widespread
  Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
  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 facility policy review, medical record review, and interview, the facility failed to convey the resident's funds and a final accounting of those funds for residents who were discharged , evicted, or expired within 30 days to the individual or probate jurisdiction administering the resident's estate for 60 (Residents #61, #83, #252, #304, #305, #306, #307, #308, #309, #310, #311, #312, #351, #352, #353, #354, #355, #356, #357, #358, #359, #360, #361, #362, #363, #364, #365, #366, #367, #368, #369, #370, #371, #372, #373, #374, #375, #376, #377, #378, #379, #380, #381, #382, #383, #384, #385, #386, #387, #388, #389, #390, #391, #392, #393, #394, #395, #396, #397, #398) of 64 residents reviewed. The findings include: Review of the facility's policy titled, Resident Refund Policy, revised [DATE], revealed .To ensure that all residents accounts are reconciled and maintained according to federal and state regulations .It is our policy that the Business Office Manager and Administrator will be responsible for…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-10-03 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, medical record review, observations, and interviews, the facility failed to use good hygiene practices and techniques, to change gloves and wash hands between tasks, to keep the ice machine clean and sanitary to prevent contamination of the ice, sanitize visibly soiled equipment associated with ice handling, and to wear hair restraints to prevent hair from contacting food. The findings include: Review of the facility's policy titled, Food Services, revised December 2008, revealed .Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing .Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens . Review of the facility's policy titled, Ice Machines and Ice Storage Chests, revised January 2012, revealed .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .Clean and sanitize 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-10-03 · tag F0908 — failed to keep essential equipment working — widespread
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on the facility policy review, observations, and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. The findings include: Review of the facility's policy titled, Maintenance Service, revised December 2009, revealed, .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Functions of maintenance personnel include, but are not limited to .Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines .Maintaining the building in good repair and free from hazards .Providing routinely scheduled maintenance service to all areas .The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner .A copy of the maintenance schedule shall be provided 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-03 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, Facility Assessment Tool, medical record review, observations, and interviews, the facility failed to ensure respect and dignity was maintained for 1 (Resident #253) of 2 sampled residents reviewed by failing to provide communication in the resident's native language. The findings include: Review of the facility's policy titled, Translation and/or Interpretation of Facility Services, dated 11/2020, revealed, .This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility .The coordinator of this facility's language access program is the director of social services, or his/her designee .All LEP persons shall receive a written notice in their primary language of their rights to obtain competent oral translation services free of charge .A staff interpreter who is trained and competent in the skill of interpreting .Family members and friends shall not be relied upon…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-03 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately 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 facility policy review, medical record review, and interviews, the facility failed to notify Responsible Party and Physician for a fall for 2 (Residents #48 and #68) of 13 residents reviewed. The facility also failed to notify Responsible Party of weight loss and respiratory illness for 1 (Resident #24) of 6 residents reviewed. Facility also failed to notify Responsible Party of Sexual Abuse in a timely manner for 4 (Residents #8, #112, #126 and #200) of 11 residents reviewed. The findings include: Review of the facility's undated policy titled, Notification of Changes, revealed, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Review of the medical records revealed Resident #48 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses which included Shortness of Breath,…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-03 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  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 policy review, medical record review, facility reported incident, and interview, the facility failed to ensure 1 (Resident #201) of 2 sampled residents reviewed were free from the use of physical restraints. The findings include: Review of the facility policy titled, Restraint Free Environment, dated 8/8/2023, revealed, .It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of the restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Using bed rails to keep the resident from voluntarily getting out of bed .Using devices in conjunction with a chair .that the resident cannot remove and prevents the resident from rising .Placing a chair or bed close enough to a wall that the resident is prevented from rising out of the chair or voluntarily getting out of bed . Review of the facility investigation…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-03 · tag F0609 — failed to report abuse allegations — isolated
  Timely 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 facility policy review, facility investigation review, medical record review, and interview, the facility failed to report allegations of resident-to-resident sexual abuse to the State Agency (SA) and Adult Protective Services (APS) within the required guidelines. On 8/16/2023 staff observed and reported Resident #200 having nonconsensual sexually aggressive contact with Residents #8, #112, and #126. The allegations of sexual abuse were not reported to the SA and APS until 8/22/2023. The findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, revised 2017, revealed, .reports of resident abuse .shall be promptly reported to local, state, and federal agencies .thoroughly by facility management .investigations will also be reported .Administrator will keep the resident and his/her representative (sponsor) informed of the the progress of the investigation Administer will ensure that any further potential abuse .is prevented .All alleged violations involving abuse .will…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-03 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to conduct a thorough investigation for allegations of resident-to-resident sexual abuse which involved 4 residents (Resident #8, #112, #126 and #200) reviewed. The findings include: Review of the facility policy titled, Abuse Investigation and Reporting, revised 2017, revealed, .reports of resident abuse .shall be promptly reported to local, state, and federal agencies .thoroughly by facility management .investigations will also be reported .Administrator will keep the resident and his/her representative (sponsor) informed of the the progress of the investigation Administer will ensure that any further potential abuse .is prevented .All alleged violations involving abuse .will be reported by the facility Administrator, or his/her designee, to .State licensing/certification agency .local/State Ombudsman .Resident's Representative .Adult Protective Services .alleged violations of abuse .will…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-03 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and interview, the facility failed to send a copy of the transfer notice to a representative of the Office of the State Long-Term Care Ombudsman for 4 (Residents #30, #34, #48, and #118) of 4 residents reviewed. The findings include: Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], discharged on 8/29/2023, and readmitted on [DATE] with diagnoses which included Lymphedema, Hyperlipidemia, and Chronic Embolism and Thrombosis. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] for Resident #30 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Review of Resident #30's medical record revealed the Ombudsman was not notified Resident #30's discharge. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Hypertensive Urgency, and Combined Rheumatic Disorders of Mitral, Aortic and Tricuspid…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$252,242 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $252,242 — penalty dated 2023-10-03
• Medicare payment denial — starting 2023-11-09 for 74 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 HILL VALLEY HEALTHCARE — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 6 rows in the source record cover these 3 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.

What families pay in TN