Alton Memorial Rehab & Therapy
1251 College Avenue, Alton, IL 62002 · Non profit - Corporation · 64 certified beds · (618) 463-7330 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (4/5)
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 4 actual-harm citations
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $15,626 in federal fines (most recent 2024-10-10)
- its facility-reported quality-measure rating is low (2/5)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 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 | 28.6% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.0% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 6.0% | 54.2% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 9.3% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 27.9% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 30.8% | 18.3% | 18.9% | worse |
| Long-stay residents with pressure ulcers | 12.3% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 27.5% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 18.9% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.3% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 82.9% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.2% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.2% | 13.9% | 12.0% | worse |
§ 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.
62.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 286 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 51.7% 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 145 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 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 48% 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 | 62.3%CMS range 56.1–67.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 9.3–14.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 51.7% | 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 | 69.0% | 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 | 43.5% | 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 | 94.4% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 2.5% | 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 | 6.0%CMS range 4.2–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 64 beds and averages 45.6 residents a day — about 71% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.446 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 4.17 hrs/resident/day on weekends vs 4.73 on weekdays — 12% thinner on weekends. RN hours go from 0.98 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% 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.
24 citations, most serious first. The 14 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · Gcited before2026-01-06 · 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 follow fall policy and procedures, and staff failed to use a gait belt when transferring a resident, for 1 (R2) of 3 residents reviewed for accidents. This failure resulted in a cognitively impaired resident (R2) being transferred to the emergency room after hitting her head. R2 had to get an EKG, blood work, head CT and chest x-ray. Using the reasonable person approach, this failure caused pain, discomfort and invasive interventions during an emergency room visit.Findings Include: R2's Resident Profile Report (Care Plan) dated 11/26/2025, documents R2 was at risk for falls and requires assistance with transfers and ambulation. The care plan states, Please ensure my bed is at an appropriate height at all times and call light is within reach. No documentation if gait belt should be used or how many staff to transfer R2 or mode of transfer. R2's Active Medication List documents Apixaban (blood thinner) 5 milligrams (mg) BID (twice a day) for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-10-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide timely and complete incontinent care for 5 of 5 residents (R13, R23, R24, R31, R33) reviewed for incontinent care in a sample of 33. This failure resulted in R23 laying in urine all night, feeling dirty, like a fool and embarrassed. Findings include: 1. R23's Care Plan, not dated, documents R23 is occasionally incontinent of urine of bladder and continent of bowel. Please provide frequent toileting and peri care after each incontinent episode, requires extensive assist with ADL's (activities of daily living), R23's Minimum Data Set, dated 8/20, documents R23 is alert and oriented x4, occasionally incontinent of urine, and requires assistance from staff for toileting. On 10/7/2024 at approximately 9:00 AM, observed V5, CNA, providing R23 incontinent care. R23 was incontinent of urine. V5 pulled back covers and opened R23's incontinent brief. V5's incontinent brief was heavily soiled with urine. V5 then cleansed R23's peri and groin area. V5 then…
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 · G2024-10-10 · 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, record review, and observation the facility failed to ensure residents are free from significant medication errors for 1 of 6 (R195) residents reviewed for medication administration in a sample of 33. A delay of 6 days in getting the antibiotic started to treat UTI as ordered by the Physician Assistant caused R195 to become confused, have abdominal pain, increased leg pain, and missed some therapy sessions. Findings include: R195's face sheet, print date of 10/8/24, documented R195 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, Sjogren syndrome with peripheral nervous system involvement, Parkinson's disease, anemia, obstructive sleep apnea, and rheumatoid arthritis. R195's MDS (Minimum Data Set) dated 9/4/24, documented R195 is mildly cognitively impaired. R195's Physician Progress Notes by V31 PA (Physician Assistant) dated 9/27/24 at 8:51 AM documented, TI (urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-05-10 · 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 ensure a safe transfer for 1 of 3 residents (R2) reviewed for falls in the sample of 13. This failure resulted in R2 sustaining a large, abrasion/laceration on her right calf while being transferring without the use of a gait belt and needing wound care. Findings include: R2's Physician Order Sheet for May, 2024 documents a diagnosis of abnormal weight loss, hereditary hemochromatosis, unspecified severe protein calorie malnutrition, alcoholic hepatitis without ascites, chronic obstructive pulmonary disease, disorder of iron metabolism, irritable bowel syndrome with diarrhea, body mass index 19.9 or less, adult, arthropathic psoriasis, monoclonal gammopathy, ankylosis, spondylitis lumbar region. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact for decision making of activities of daily living. I use a wheelchair and a walker and have no impairment on my upper and/or lower extremities. R2's Resident Profile Page dated 4/5/2024…
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 · D2026-01-06 · 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 observation, interview and record review the facility failed to notify the provider of a fall with injury for 1 (R2) of 3 residents reviewed for accidents.Findings include: R2's Resident Profile Report (Care Plan) dated 11/26/2025, documents R2 was at risk for all and requires assistance with transfers and ambulation. Please ensure my bed is at an appropriate height at all times and call light is within reach. R2's SBAR dated 12/22/2025 at 8:05 AM, V5, LPN (Licensed Practical Nurse) documents R2 had knees buckle approx. 12 hours ago where resident's face had come in contact with handrail in shower room resulting in dentures breaking. Resident has bleeding and pain noted to gums/mouth. NP (Nurse Practitioner) present and gave order to send R2 to ER for evaluation and treatment. R2 complained of mouth pain 8/10 on pain scale. Medications included Apixaban (blood thinner medication) 5 mg (milligrams) BID (twice a day.) On 12/23/2025 at 9:50 AM V5, LPN stated she worked day shift on 12/22/2025 and arrived…
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 · E2025-12-05 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure food was palatable for 4 of 4 residents (R4, R12, R32, R44) reviewed for nutritional services in the sample of 25.1- R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE]. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact and is independent with eating. R4's Physician Order dated 3/27/2025 documents R4 has a Regular Diet. On 12/2/2025 at 11:35 AM R4 stated the food in the facility is terrible and tastes like s*. R4 stated residents have brought up the food issue regarding taste and temperature every month at resident council and the facility has failed to change things. R4 stated she eats in her room and every meal tray she receives is cold. R4 stated the food is well done and hard, the pasta is gummy, and everything is tasteless. R4 stated she had written a letter to the head chef regarding the food and the chef has discussed the resident's concerns and no changes to the food have been made.…
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 · D2025-12-05 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure respectful handling and safeguarding of 2 (R3,R4) of 2 residents' personal clothing in the sample of 25. The loss of the resident's clothing demonstrates a failure to honor the resident's right to dignity and respect for personal belongings. Findings include:On 12/02/2025 3:28 PM, V10, R3's family member, stated she is happy with everything at the facility and with her father's care except that the facility has lost her father's clothes. She stated that has been an ongoing issue.On 12/4/25 at 1:30 PM, R3 and R4 both stated they are missing clothes for months. R4 stated that she has told V1, Administrator, and nothing has been found. R3 & R4 are both documented as being long term care residents of the facility.On 12/4/25 at 2:17 PM, V7, Laundry/Housekeeping Supervisor stated she only washes the clothes for the long-term residents. She stated they do not wash the short-term residents' clothes. She stated the families are responsible for washing the short-term resident's clothes. She stated the laundry is down in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview that facility failed to evaluate and revise the care plan for 1 of 1 (R22) residents reviewed for care plans in a sample of 25.R22's Undated Face Sheet documents R22 was re-admitted to the facility on [DATE] and has a medical diagnosis of Hypertensive Disorder, Osteoporosis, Focal to Bilateral Tonic-Clonic Epileptic Seizures.R22's Minimum Date Set (MDS) dated [DATE] documents R22 is moderately cognitively impaired and needs partial/moderate assistance with sitting to standing, chair/bed to chair transfers, and toilet transfers.R22's Care Plan Last Reviewed 10/17/25 documents (R22) is at risk for falls. I require assistance with transfers and ambulation. Please ensure my bed is at an appropriate height at all times. Please ensure my call light is within reach when I am in my room. 8/28/25: call don't fall sign in bathroom; labs. I had a fall on 5/24/25 intervention: frequent observations/staff interaction when passing by and PLEASE CALL, DON'T FALL sign in room. I had a fall…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · 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 implement current progressive interventions to prevent falls for 1 of 6 (R22) residents reviewed for falls in a sample of 25.R22's Undated Face Sheet documents R22 was re-admitted to the facility on [DATE] and has a medial diagnosis of Hypertensive Disorder, Osteoporosis, Focal to Bilateral Tonic-Clonic Epileptic Seizures.R22's Minimum Date Set (MDS) dated [DATE] documents R22 is moderately cognitively impaired and needs partial/moderate assistance with sitting to standing, chair/bed to chair transfers, and toilet transfers.R22's Care Plan Last Reviewed 10/17/25 documents (R22) is at risk for falls. I require assistance with transfers and ambulation. Please ensure my bed is at an appropriate height at all times. Please ensure my call light is within reach when I am in my room. 8/28/25: call don't fall sign in bathroom; labs. I had a fall on 5/24/25 intervention: frequent observations/staff interaction when passing by and PLEASE CALL, DON'T…
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 · D2025-12-05 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to follow physician prescribed therapeutic supplement order for 1 of 1 residents (R33) reviewed for nutritional services in the sample of 25.Findings include:1-R33's Face Sheet documents R33 was admitted to the facility on [DATE] with diagnoses including protein calorie malnutrition and end stage renal disease (ESRD).R33's Minimum Data Set (MDS) dated [DATE] documented R33 was cognitively intact, ambulated with wheelchair and walker, and was on a therapeutic diet.R33's Physician Order dated 10/30/25 documents Renal Diet.R33's Physician Order dated 10/6/25 documents Ensure High Protein three times daily.R33's Registered Dietitian Nutrition Evaluation dated 10/6/25 documents, Increased nutrient needs r/t (related to) ESRD as evidenced by dialysis treatment. Inadequate oral intake r/t loss of appetite/social/environmental circumstances as evidenced by physical finding. The nutrition intervention added was Ensure High Protein three times…
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 · D2025-01-10 · tag F0802 — failed to prepare enough nourishing food — isolatedProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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 adequately staff the dietary department to ensure meals were served in a timely manner for 1 of 5 residents (R9) reviewed for food and nutrition services in the sample of 9. Findings include: R9's Physician Orders document R9 was admitted to the facility on [DATE]. R9's Face Sheet documents R9 has diagnoses including heart disease, peripheral vascular disease, and protein calorie malnutrition. R9's Minimum Data Set (MDS) dated [DATE] documented R9 was cognitively intact, independent with eating, and ambulated with wheelchair and walker. R9's Care Plan documents goal to improve nutritional status. R9's Physician Orders document 12/16/24 order for carbohydrate controlled diet. On 1/9/25 at 12:47 PM, R9 stated dinner is never on time and has recently received dinner as late as 6:30 PM and 6:35 PM. On 1/9/25 at 12:57 PM, V10, Certified Nursing Assistant (CNA) stated meal service tends to run slower in the evenings. On 1/9/25 at 2:40 PM, V16,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure all abuse investigations were reported to the designated representative and to other officials in accordance with State law, including State Survey Agency within five working days of the incident for 1 of 7 residents (R2) reviewed for reporting in the sample of 10. Findings include: On 1/2/2025 at 12:28 PM, V1, Administrator stated (V6), Licensed Practical Nurse LPN) was the nurse working the day (R2's) wet sheets were changed and the male certified nursing assistant (CNA) was (V7). V7 was the one who was working (R2's) hall. V1 stated, I did not get any statements or have any allegations of abuse related to (R2). I know the family was upset about (R2's) bed being wet but I do not have any statements or anything in writing voicing any other concerns, and nothing related to any abuse allegations. All abuse investigations for the past six months were requested and reviewed and there was no abuse investigation provided for R2. On 1/2/2024 at 12:43 PM, V7, Certified Nursing Assistant (CNA) stated, I laid (R2) gently on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the Facility failed to ensure all abuse allegation were thoroughly investigated for 1 of 5 residents (R2) reviewed for investigation of abuse in the sample of 10. Findings include: On 1/2/2025 at 12:28 PM, V1, Administrator stated, (V6, Licensed Practical Nurse LPN) was the nurse working the day that (R2's) wet sheets were changed and the male certified nursing assistant (CNA) was (V7). V7 was the one who was working (R2's) hall. V1 stated, I did not get any statements or have any allegations of abuse related to (R6). I know the family was upset about (R2's) bed being wet but I do not have any statements or anything in writing voicing any other concerns, and nothing related to any abuse allegations. All abuse investigations for the past six months were requested and reviewed and there was no abuse investigation provided for R2. On 1/2/2024 at 12:43 PM, V7, stated (R2) was very slow in her movements. (R2) did not like to move a lot, I helped her to transfer from her recliner to her wheelchair, and then her wheelchair to her bed, when I turned…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-10-10 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 store medications and ensure expired medications were discarded when appropriate. This has the potential to affect all 45 residents living in the facility. Findings include: On 10/7/2024 at 9:43 AM, the facility's East Wing Medication Storage Room was inspected. The refrigerator in the medication room contained the following medication: 1. A Dulcolax suppository with expiration date 1/20/2023. 2. Two Acetaminophen 650mg suppositories with expiration date 4/2024. The East Wing medication room also had the following medication: 3. A large bottle of stool softener with expiration date 3/2022. On 10/7/2024 at approximately 9:50 AM, V4, Licensed Practical Nurse, LPN stated the medication in the storage rooms is stock medication. V4 stated the Dulcolax and Acetaminophen suppositories and the stool softeners are stock medication and can be used for everyone as long as they have an order and no allergies. V4 stated expired medications are not to be used and are to be destroyed. On 10/10/24 at 10:06 AM, V32,…
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 10 citations
- Potential for harm · D2024-10-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interview the facility failed to ensure a resident was treated with dignity and had needs met timely for 1 of 3 (R23) residents in a sample 33 observed for dignity. Findings include: R23's Care Plan, noted dated, documents R23 is able to make her needs known, pleasant to talk to and can communicate needs with staff. R23's Minimum Data Set, dated 8/20, documents R23 is alert and oriented x4 occasionally incontinent of urine and requires assistance from staff for toileting. On 10/7/2024 at approximately 9:00 AM, observed V5, CNA, providing R23 incontinent care. R23 was incontinent of urine. V5 pulled back covers and opened R23's incontinent brief. V5's incontinent brief was heavily soiled with urine. V5 then cleansed R23's peri and groin area. V5 then assisted R23 over onto her right side. R23's gown, incontinent brief, incontinent pad and sheets were soaked with urine. R23's sheets were soaked up to her upper back. V5 removed the soiled incontinent brief revealing multiple deep, red indentations in skin. V5 then cleansed R23's left buttock. V5 then removed…
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 · D2024-10-10 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete the periodical comprehensive Minimum Data Set Assessments in the required time frame for 3 of 3 (R16, R23, R28) residents reviewed for resident assessments in a sample of 33. Findings include: 1. R28's Face Sheet, not dated, documents that R28 was admitted [DATE]. R28's Minimum Data Set (MDS), dated [DATE], documents Quarterly Assessment. Signed 8/23/2024. The facility provided a form that documents (R28) Target date: 8/9/2024, Submission and Processing date:10/8/2024. Warnings: Record submitted late. The submission date is more than 14 days after Z0500B on this new assessment. 2. R23's Face Sheet, not dated, documents that R23 was admitted [DATE]. R23's Minimum Data Set (MDS), dated [DATE], documents Quarterly Assessment. Signed 9/4/2024. The facility provided a form that documents (R23) Target date: 8/20/2024, Submission and Processing date: 10/8/2024. Warnings: Record submitted late. The submission date is more than 14 days after Z0500B on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-10 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner promotes each resident's rights, physical, mental, and psychosocial well-being. This failure has the potential to affect all 33 residents residing in the facility. R23's Care Plan, not dated, documents R23 is occasionally incontinent of urine of bladder and continent of bowel. Please provide frequent toileting and peri care after each incontinent episode, requires extensive assist with ADL's (activities of daily living), R23's Minimum Data Set, dated 8/20, documents R23 is alert and oriented x4 occasionally incontinent of urine and requires assistance from staff for toileting. On 10/7/2024 at approximately 9:00 AM, observed V5, CNA, provide R23 incontinent care. R23 was incontinent of urine. V5 pulled back covers and opened R23's incontinent brief. V5's incontinent brief was heavily soiled with urine. V5 then cleansed R23's peri 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 · F2024-02-06 · 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 interview, observation, and record review, the facility failed to ensure Dietary Staff wear appropriate hair and beard nets, failed to perform proper hand hygiene and/or wear gloves, and failed to check temperatures of food, including all diets (regular diets, special diets, and pureed foods) prior to serving to residents, to prevent contamination and foodborne illness. This failure has the potential to affect all 52 residents living in the facility. The findings include: On 2/1/24 at 2:20 PM, R1, stated, The food is horrible, I wouldn't feed it to my dog. It's usually between warm and cold. The outside may be warm, but the inside is cold. It comes from the hospital, and by the time we get it, it has cooled down. On 2/5/24 at 8:00 AM, V6, Food Service Director, stated All of the food at the facility is produced at the hospital and transported in hot boxes via hospital van, to the facility, it is unloaded, and is placed in a plug-in warmer. The facility's dietary department will prep the food, such as pureed, etc., as needed for special meals, and the cart is brought up 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 · Fcited before2023-11-30 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store medications and label tuberculin vials and insulin pens. This has the potential to affect all 40 residents living in the facility. Findings include: On 11/27/2023 at 11:00 AM the facility's [NAME] Wing Medication Storage Room was inspected. The medication room contained the following medication: 1. A multi-dose vial of Tubersol (TB) with no open date. V6, Licensed Practical Nurse (LPN), verified the medication was open and in use. On 11/27/2023 at 11:07 AM, V6 stated the multi-dose vial was open and in use. V6 stated when she opens the vial, she places an open date. V6 stated this is the facility process. V6 stated she was not sure if the vial had an open date as she had not opened it. V6 stated the vial of Tubersol should have an open date. V6 stated Tubersol has a different expiration date once the bottle is opened. V6 stated it (Tubersol) is good for 30 days. V6 stated placing the open date on the bottles tells them when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-30 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
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 organize and have a monthly Resident Council Meeting for 7 of 7 residents (R1, R5, R6, R13, R18, R19, R214), reviewed for Resident Council meetings in the sample of 33. The findings include: On 11/28/23 at 1:30 PM, a Resident Council Meeting was held in a dining room with R1, R6, R13, and R18 in attendance. 1. On 11/28/23 at 1:40 PM, R6 (Resident Council President) stated, We definitely do not have a meeting every month, are we supposed to? I think we have only had one or two meetings that I know of. R6's Electronic Medical Record (EMR), visit list, documents R6 was admitted to the facility on [DATE]. R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact with a Basic Interview for Mental Status (BIMS) of 15. A Score of 13-15 indicates an intact cognitive response, 8-12 indicates a moderate cognitive impairment, and 0-7 indicates a severe cognitive impairment. 2. On 11/28/23 at 1:42 PM, R13 stated, We do not have a meeting every…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-30 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 an ongoing program of activities for 6 of 6 residents (R1, R5, R6, R13, R18 and R19) reviewed for activities in a sample of 33. Findings include: 1. On 11/28/23 at 1:30 PM, a Resident Council Meeting was held in a dining room with R1, R6, R13, and R18 was in attendance. On 11/28/23 at 1:40 PM, R6, Resident Council President, stated, I think the activities are cutting short. The activity girl drives the bus and does other jobs and our activities are slowing down. R6's electronic medical record, visit list, documents R6 was admitted to the facility on [DATE]. R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact with a Basic Interview for Mental Status (BIMS) of 15. A Score of 13-15 indicates an intact cognitive response, 8-12 indicates a moderate cognitive impairment, and 0-7 indicates a severe cognitive impairment. On 11/28/23 at 1:42 PM, R13 stated, The activities here are slowing down. We used to play bingo…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-30 · 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 complete incontinent care for 6 of 6 (R1, R4, R5, R25, R205, R212) residents reviewed for incontinent care in a sample of 33. Findings include: 1. On 11/28/2023 at 3:00 PM, R1 stated she was supposed to have a test for her urine and there wasn't a urine collector in the toilet and now she had an accident and wet herself. R1 was sitting in her wheelchair, out in the hallway in front of her room. The front of R1's pants were wet in front from the right groin area over to her pelvic and abdominal fold area. At 3:17 PM, V17, Certified Nurse Assistant (CNA) took R1 into her room. V17 donned gloves without benefit of hand hygiene. V18, Licensed Practical Nurse (LPN) then entered R1's room, donned gloves without benefit of hand hygiene. V17 collected items needed to perform incontinent care on R1 then placed gait belt on R1. V17 and V18 assisted R1 to a standing position in the bathroom. V18, pulled down R1's pants and removed 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 · E2023-11-30 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 change and date the oxygen tubing and humidification water bottles on the oxygen concentrators and failed to store needed equipment in a safe and sanitary manner for 6 of 6 (R1,R17, R35, R37, R204, R255) residents reviewed for respiratory care in a sample of 33. Findings include: 1. On 11/27/23 at 8:50 AM, R255 was observed resting in bed. R255 was receiving O2 (oxygen) via nasal cannula at 2 LPM (liters per minute) as documented on the physician order records. The oxygen tubing was attached to a bottle of water connected to an oxygen concentrator. There was no date on the oxygen tubing, nor was the bottle of water dated that connected to the oxygen concentrator. On 11/29/23 at 8:30 AM, R255 was in bed with O2 running at 2 LPM via nasal cannula connected to a bottle attached to the oxygen concentrator. The bottle did not contain any water for humidification. There was no date on the bottle or the oxygen tubing. R255's electronic medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-30 · 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 perform proper hand hygiene and glove changes per current standards of practice and failed to secure a catheter bag off the floor for 5 of 5 (R1, R20, R104, R209, R213) residents reviewed for infection control in a sample of 33. Findings include: 1. R209's admission Record, undated, documents R209 was admitted to the facility on [DATE]. R209's Electronic Medical Record, documents R209's Diagnosis includes: Abdominal Aortic Aneurysm (AAA), Acute Cystitis, Acute Kidney Failure (AKF), Anemia, Arteriosclerotic Heart Disease (ASHD), Cardiomegaly, Candida Stomatitis, CHF, COPD, Chronic resp. failure, Diverticulosis, Flaccid neuropathic bladder, Mesothelioma, Hyperlipidemia, macular degeneration, Portal Hypertension (HTN), Thrombocytopenia, Dementia, Fracture right humerus. R209's Care Plan, dated 11/8/23, documents Bladder and Bowel: R209 is incontinent of bowel at times. Interventions: provide peri-care after episodes of incontinence, has a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$15,626 in federal fines across 1 penalty.
- $15,626 — penalty dated 2024-10-10
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 BJC HEALTHCARE — 4 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 | 4 of 5 | 4.3 | -0.3 vs chain |
| Health inspection | 4 of 5 | 4.3 | -0.3 vs chain |
| Staffing | 4 of 5 | 3.5 | +0.5 vs chain |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 3 homes this chain runs (chain average 4.3★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| AYRES, GARY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2010 |
| BRAASCH, DAVID | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 04/01/2006 |
| BYRNE, ROGER | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2015 |
| CHILDERS, TIMOTHY | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| ERKER, MELISSA | Individual | CORPORATE DIRECTOR | since 01/01/2010 |
| GOINS, SHEILA | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| HARMS, CRAIG | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| HUDDLESTON, EBONY | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| LOY, KENNETH | Individual | CORPORATE DIRECTOR | since 01/01/2003 |
| MAGRUDER, JOAN | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| PATTON, TANYA | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| RYRIE, EDWARD | Individual | CORPORATE DIRECTOR | since 01/01/2011 |
| TCHOUKALEFF, MICHAEL | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| THOMPSON, STEPHEN | Individual | CORPORATE DIRECTOR | since 01/01/2010 |
| TRZASKA, KENNETH | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| TURNER, GEOFFREY | Individual | CORPORATE DIRECTOR | since 01/01/2019 |
| TURPIN, DEBRA | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| ALTON MEMORIAL HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2015 |
| BETHESDA HEALTH GROUP INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2015 |
| BJC HEALTH SYSTEM | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 03/11/2016 |
| CHRISTIAN HEALTH SERVICES DEVELOPMENT CORPORATION | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2015 |
| DIANATI, BEHFAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| LISZEWSKI, KATHRYN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/05/2024 |
CMS files one row per role, so the 30 rows in the source record cover these 23 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $675K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
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 145121. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-05, 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 →
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