Lutheran Home For The Aged

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.

64.4% 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 1,933 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 73.4% 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 654 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 0.54 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% 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 354 beds and averages 223.8 residents a day — about 63% occupied, or roughly 130 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.35 hrs/resident/day on weekends vs 3.64 on weekdays — 8% thinner on weekends. RN hours go from 0.98 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

Deficiencies are 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.

37 citations, most serious first. The 18 most serious are shown; the remaining 19 are one tap away and print in full.

• Actual harm · Gcited before2025-09-16 · 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

  Based on interview and record review the facility failed to safely reposition a resident during care. This failure resulted in R1 falling from her bed and sustaining a right patella fracture. This applies to 1 of 4 residents (R1) reviewed for safety in the sample of 6.The findings include:R1's face sheet shows she has diagnoses including Cerebrovascular Accident, hemiplegia of the right side, dysarthria and pain in right leg.R1's active care plan initiated on 5/29/23 she has impaired cognitive and decision making, limited physical mobility, is at risk for falls, and requires staff assistance for turning and bed mobility with instruction cues and hand guidance. A nursing progress note completed for R1 on 8/25/25 at 10:00 PM states, @ 9:15 pm someone calling this writer's name. I immediately attended to the room where the name calling coming from and upon entering the room noted resident (R1) on her back lying on the floor with both legs extended with {V6) holding resident's head. Per {V6} she's giving a bed bath and resident rolled off the bed and fell on the floor. A nursing…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-02 · 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

  Based on interview and record review the facility failed to ensure a resident was safely transferred using a mechanical sit to stand lift for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being assisted to the ground and sustaining a proximal tibia and fibula fracture of her right leg. The findings include: R1's Nursing Notes dated 6/28/25 shows that at 1:00 PM, the Certified Nursing Assistant said that R1 passed out while providing care to R1 after having an extra large bowel movement while using a sit to stand lift and R1 was assisted to the floor with two person assist. R1's Right Tibia/Fibula X-ray dated 6/28/25 shows, There is a fracture involving proximal tibia and fibula (bones of the upper shin) with minimal displacement. On 7/2/25 at 10:12 AM, V3, Certified Nursing Assistant (CNA) said that on 6/28/25 after lunch, she was assisting R1 to use the toilet. V3 said that she placed R1 on the toilet from her wheelchair using the mechanical sit to stand lift. V3 said that once R1 was done using the bathroom, she lifted her up from the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-30 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate pain control for a resident with a history of cancer and compression fracture. This failure resulted in R1 experiencing increased pain from 4/21/2025 to 4/24/2025. This applies to 1 of 3 (R1) residents reviewed for pain in the sample of 3. The findings include: R1's current admission Record shows R1 is an [AGE] year-old female resident with a history of lung cancer and compression fracture who was admitted on [DATE]. On 4/30/2025 at 10:00AM, R1 was observed lying in bed resting comfortably and showing a slight grimace with movement. On 4/30/2025 at 10:00AM & 10:18AM, R1 said her pain was 4 out of 10 and a 4 was acceptable. R1 said her pain is more controlled now. R1 said she doesn't like using the numbers to describe the pain. R1 said she had increased pain when she came into the facility because the facility had trouble getting her medication. On 4/30/2025 at 11:04PM, V5 Nurse Practitioner (NP) said she saw [R1] on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-21 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to communicate and effectively treat a resident's pain; and failed to verify and obtain a resident's ordered pain medication in a timely manner for 1 of 1 resident (R425) reviewed for pain in the sample of 35. These failures resulted in R425 experiencing continued pain and emotional anguish. The findings include: On 11/19/24 at 11:46 AM, R425 was lying in bed, on his left side. R425 had a catheter drainage bag on each side of the bed frame. R425 said he's been sick since March and was in the hospital. R425 said the hospital found out that he had urine draining into his right upper leg area (fistula - an abnormal opening in the urinary tract). R425 said that caused him to develop an abscess in his right upper leg. R425 said they had to drain out the fluid from his leg and now he has a catheter in his penis to protect the fistula and a suprapubic catheter (directly through the abdominal wall, into the bladder) to empty most of his urine. R425 said his pain seemed to be getting worse. R425 said in the hospital he…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcers and failed to identify a pressure ulcer for 2 of 3 residents, R1 and R3, reviewed for pressure injuries in the sample of 3. These failures resulted in R1 developing a Stage 3 sacral pressure wound which later became an infected Stage 4 pressure ulcer and R3's pressure wound not receiving wound care treatment until it was an unstageable pressure injury. The findings include: On 11/6/24 at 10:42 AM, V4, Wound Care Nurse, V7, Registered Nurse, and V8, Certified Nursing Assistant transferred R1 from her chair to her bed to provide wound care. R1 had a half dollar coin sized wound to her sacrum. R1's admission Record dated 11/7/24 shows R1 was admitted to the facility on [DATE]. R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation shows R1 was At Risk on 10/20/23, was a High Risk on 11/3/23, a Moderate Risk on 12/13/23 and 1/4/24, High Risk again on 1/15/24 and Moderate Risk on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to safely transfer two of two residents (R1, R3) reviewed for safe transfers in the sample of three. This failure contributed to R1 falling forward out of her wheel chair which required a transfer to a local hospital where R1 was diagnosed with a brain hemorrhage. The findings include: 1. R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, traumatic subdural hemorrhage, palliative care, glaucoma, dementia, and macular degeneration. R1's Fall Scale dated September 20, 2024 shows she was at a moderate risk of falling. The facility's Incident Report shows on September 20, 2024, R1 had a fall from her wheel chair when she impulsively and abruptly put her feet down on the floor while being propelled by staff. She landed face down to the floor with right side of face touching the floor. A small cut was noted, the arm of her eyeglasses's was bent. R1 became more confused…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was transferred safely for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 obtaining a right surgical neck fracture (Right shoulder area). This past non-compliance occurred from February 19, 2024-February 23, 2024. The findings include: R1's admission Record dated February 28, 2024 shows she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, quadriplegia, right and left hand contractures, heart disease, low back pain, and muscle spasms. R1's diagnoses were updated February 19 & 20, 2024 to reflect pain and fracture of upper end of right humerus. R1's Minimum Data Set (MDS) dated [DATE] shows she is cognitively intact and shows R1 is dependent on staff for showering, toileting, and transfers. R1's Fall Scale dated January 13, 2024 shows she was a moderate risk for falls. R1's Care Plan revised on June 23, 2023 shows R1 requires a mechanical lift with…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2023-10-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a gait belt was used to safely transfer a resident. This failure contributed to R1 falling and sustaining a right femur fracture requiring hospitalization and surgical intervention. This applies to 1 of 5 residents (R1) reviewed for safety/supervision in the sample of 5. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnoses including: transient ischemic attack, restless leg syndrome, pain in right leg and atrial fibrillation. R1's 9/14/23 facility assessment shows her cognition is intact, and she requires extensive 1 staff assistance with transfers. R1's care plan shows she has an ADL (Activities of Daily Living) self- care deficit due to having a cerebral vascular accident (stroke) with right sided weakness. R1's 8/10/22 fall risk care plan shows she is at a moderate risk for falls related to having weakness and gait and balance problems. R1's 9/20/23 6:00 AM, nursing progress note completed by V5 (Licensed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-22 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were three (3) medication errors out of 30 medication opportunities, resulting in a 10% medication error rate. Findings include:On 01/21/2026 at 9:30 AM, Medication observation with V13 (Licensed Practical Nurse) completed for R178. R178 has a diagnosis of heart failure, hypertension, and chronic obstructive pulmonary disease. V13 gave Lamotrigine Oral Tablet 150 MG, Bumetanide Oral Tablet 1 MG, and Carvedilol Oral Tablet 6.25 MGPer the Physician order sheet dated January 2026, it reads:1-Lamotrigine Oral Tablet 150 MG, Give 1 tablet by mouth two times a day. Scheduled for 8:00 AM and 8:00 PM.2-Bumetanide Oral Tablet 1 MG, Give 1 tablet by mouth two times a day. Scheduled for 8:00 AM and 5:00 PM.3-Carvedilol Oral Tablet 6.25 MG. Give 1 tablet by mouth two times a day. Scheduled for 8:00 AM and 8:00 PM.On 1/21/2026 at 9:45 AM, V13 said, I am expected to administer medication one hour before or one hour after the scheduled times, and I am a float…

  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 · Dcited before2025-07-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was safely transferred with a mechanical lift, resulting in the resident sustaining a fractured toe. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in the sample of 3. R1's BIMS-Brief Interview of Mental Status dated 07/16/25 shows, R1 is Cognitively Intact.On 07/16/2025 at 9:51AM, R1 was sitting in her wheelchair. R1 was wearing a surgical shoe on her right foot. R1's right great toe had a grey/black bruise.On 07/16/2025 at 9:51AM, R1 said, I have used a wheelchair for the past 8 years. I used to be able to use a slide board with two persons assist. Currently, I am a full body mechanical sling lift. I have a displaced fracture to my right toe. On Sunday (07/13/2025) after lunch I was being transferred from the wheelchair to the bed with a full body mechanical sling lift. I was sitting back in the sling with my feet dangling in the air. Usually, the staff will guide my feet, this time my…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to safely transport a resident in their wheelchair. This applies to 1 of 5 residents (R1) reviewed for safety in a sample of 5. The findings include: R1's Facility assessment dated [DATE] showed R1 is an eighty-year-old female with severe cognitive impairment. R1 admitted to the facility on [DATE] with diagnoses which include severe dementia with agitation. The facility's Final Incident Report dated 5/12/25 showed on 5/6/25 at 6:15 PM R1 had fallen forward from her wheelchair which resulted in R1 receiving 3 sutures above her right eye. On 5/14/25 at 10:30 AM, R1 was sitting with V5, (R1's Power of Attorney-POA), at the end of the hallway. R1 was in her wheelchair with her legs behind the leg rests with her feet flat on the ground. R1 had 3 sutures along her outer right eyebrow closing a laceration approximately a half to one inch long. R1 had a bruise approximately 3-4 inches around the laceration, in various stages of healing. On 5/14/25 at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-21 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 misappropriation of resident funds did not occur for 1 of 3 residents (R1) reviewed for misappropriation of resident funds in the sample of 9. The findings include: R1's admission Record, provided by the facility on 2/21/25, showed she was admitted to the facility on [DATE] for aftercare following joint replacement surgery. R1's Progress Note dated 2/17/25 showed R1 was discharged home with a caregiver. R1's progress note dated 2/7/25 showed R1 had a follow up appointment with her orthopedic PA (Physician's Assistant) on 2/10/25. The note showed transportation was set up through Wheels on Wheels to take R1 to her appointment on 2/10/25. R1's 2/10/25 Progress note showed R1 went to her orthopedic appointment on 2/10/25. R1's facility assessment dated [DATE], showed she was cognitively intact and required substantial/maximal assistance from staff for dressing, toileting, and transfers. R1's care plan initiated on 1/30/25 showed she had limited…

  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 · D2025-02-21 · 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

  Based on interview and record review, the facility failed to notify the police when a resident's credit card was missing and could not be located for 1 of 3 residents (R1) reviewed for misappropriation of residents' funds in the sample of 9. The findings include: On 2/21/25 at 10:40 AM, V1 (Administrator) said R1 and her niece (V13) reported to the facility on 2/14/25 that V7 (another one of R1's niece's) claimed she dropped off a credit card for R1 on 2/8/24 at 10:45 AM. V1 said it was reported that the credit card was dropped off at the nurse's desk in a white hallmark envelope. V1 said she was going to call the police to report it, however, R1 did not want her to. V1 said V13 asked her to please hold off for now because all of the charges that were made on the card would be covered by the credit card company. V1 said she did not report R1's missing credit card to the local police. On 2/21/25 at 12:29 PM, R1 said she did say she did not want the police notified at that time because she wanted to give the facility time to investigate it. R1 said she also did not want police…

  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 · E2024-11-21 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure insulin was refrigerated or dated and failed to ensure controlled medications were double locked for 2 residents in the sample (R8, R172) and 4 residents outside of the sample (R367, R375, R41, R179). The findings include: 1. On 11/20/24 at 9:42 AM, the 2B unit medication cart was reviewed with V26 (RN-Registered Nurse) present. The top drawer of the cart contained an insulin pen labeled with R172's name. A multi-dose vial of insulin belonging to R375 was in the drawer. Both items were unopened and inside clear bags stating to keep refrigerated. The drawer had an opened insulin pen belonging to R367 and a multi-dose vial of insulin belonging to R41. Neither of the open insulin containers were labeled with any dates. V26 (RN) stated insulin needs to be refrigerated until it is opened. It maintains the usefulness. Any open insulin needs to be dated to know when it will expire. It needs to be discarded after 28 days. The insulin proteins can breakdown and not work effectively. 2. On 11/20/24 at 10:01 AM,…

  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 · Dcited before2024-11-21 · 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 observation, interview, and record review the facility failed to provide feeding assistance in a dignified manner and failed to utilize a catheter dignity bag. This applies to 2 of 2 residents (R108, R425) reviewed for dignity in the sample of 35. The findings include: 1. R108's admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia, lack of coordination, and need for assistance with personal care. R108's 10/2/24 Significant Change Minimum Data Set (MDS) showed he had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 0 out of 15. On 11/19/24 at 11:49 AM, V9 Certified Nursing Assistant (CNA) provided R108's feeding assistance. V9 stood over R108 during the entire noon meal while she provided feeding assistance. On 11/20/24 at 2:24 PM, V10 Memory Care Unit Manager/Registered Nurse stated staff can either sit or stand when providing feeding assistance. On 11/20/24 at 3:00 PM, V3 Assistant…

  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 · Dcited before2024-11-21 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  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 obtain a Level I Preadmission Screening and Resident Review (PASSAR) for a resident who admitted with a serious mental health diagnosis for 1 of 1 residents (R77) reviewed for PASSAR in a sample size of 35. Findings include: R77's face sheet documented that resident last admitted to the facility on [DATE] and has a past medical history not limited to major depressive disorder, recurrent dated 07/25/2023. Review of R77's care plan showed the following: has known history of displaying inappropriate behavior and/or resisting care/services. Specific behavior exhibited: paranoia in the evenings, hallucinations. She has diagnosis of dementia, delusional disorder. Date Initiated: 08/19/2022. Revision on: 08/19/2022; is an elopement risk/wanderer related to impaired safety awareness. Resident wanders aimlessly. Date Initiated: 11/09/2022; uses psychotropic medications (antipsychotic and antidepressant medications) related to behavior management, depression.…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living for a resident assessed to be dependent on staff for grooming and personal hygiene for 1 of 1 residents (R166) reviewed for activities of daily living in a sample size of 35. Findings include: R166's face sheet documented that resident last admitted to the facility on [DATE] and has a past medical history not limited to: cerebral infarction, dementia, need for assistance with personal care, problem related to care provider dependency, pain and anxiety disorder. Review of R166's functional abilities and goals assessment with effective date of 10/14/2024 documented that R166 is dependent on staff for shower/bathing and personal hygiene. Review of R166's Minimum Data Set (MDS) quarterly resident care assessment screening dated 10/15/2024 documented in section C for cognitive patterns, a brief interview for mental status (BIMS) score of 15/15 that indicated no cognitive impairment. Section GG…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-21 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure a wound vacuum was operational, failed to ensure physician orders were obtained, and failed to have care interventions in place for 1 of 3 residents (R371) reviewed for non-pressure wounds in the sample of 35. The findings include: R371's face sheet printed on 11/20/24 showed an admission date of 11/13/24 and diagnoses including but not limited to aftercare following joint replacement, displaced fracture of the left femur, and the presence of left artificial hip joint. R371's brief interview of mental status report dated 11/15/24 showed cognitively intact. On 11/19/24 at 12:09 PM, R371 was seated in an upright recliner in her room and stated she had left hip surgery a week ago. R371 said she was wet underneath her left buttocks and the aide was on her way to get her cleaned up. R371 repeatedly said she was soaked and could not understand why her pants were all wet. A wound vacuum was lying on her bed and the tubing was running under her clothing, to the left side of her body. The vacuum fluid collection…

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

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

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

Fines & penalties

$144,945 in federal fines across 6 penalties.

• $14,768 — penalty dated 2025-09-16
• $48,620 — penalty dated 2025-04-30
• $40,339 — penalty dated 2024-11-07
• $13,910 — penalty dated 2024-10-02
• $14,050 — penalty dated 2024-02-29
• $13,258 — penalty dated 2023-10-10

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.

Who owns this facility

CMS files one row per role, so the 17 rows in the source record cover these 10 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.

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

Follow the money — this home’s finances

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

This home reported $2.9M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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