Nexus Pavilion at Belleville

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.

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 180 beds and averages 113.9 residents a day — about 63% occupied, or roughly 66 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 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.74 hrs/resident/day on weekends vs 3.45 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.22 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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.

79 citations, most serious first. The 38 most serious are shown; the remaining 41 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-08-04 · 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, observation, and record review, the facility failed to provide supervision to prevent elopement for 1 (R7) of 3 reviewed for elopement in the sample of 13. This failure resulted in R7, a resident with known desire and attempts to leave the facility, eloping from the facility and found 12 miles away approximately 8 hours later by police.This failure resulted in an Immediate Jeopardy, which was identified to have begun on 7/25/25 when the R7 eloped from the facility. V1, Administrator, V2, Director of Nursing (DON), V3, Regional Nurse Consultant (RNC), and V19, Regional Director of Clinical and Operations, were notified of the Immediate Jeopardy on 7/30/25 at 4:08 PM. The surveyor confirmed by interviews, observations, and record review, the Immediate Jeopardy was removed on 8/1/25, but the noncompliance remails at Level Two due to additional time needed to evaluate implementation and effectiveness of training.The Findings Include:R7's admission Record, dated 7/28/25, documents R7 was admitted…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-06-25 · 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 residents were being monitored and supervised to prevent elopement for 1 of 3 residents (R2) reviewed for supervision to prevent elopement in the sample of 11. This failure resulted in R2 attempting to exit the facility around 2 AM on 6/10/2025. R2 was redirected but no other interventions were implemented and R2 then later eloped from the Facility on 6/10/2025 at 5:49 AM and was sent out to the hospital for six days with a diagnosis of Paranoid Schizophrenia and behaviors. The Immediate Jeopardy began on 6/10/25 when the facility failed to implement resident-centered interventions after R2 previously displayed exit seeking behaviors to prevent R2 from eloping the facility again the same day. V10, Regional Nurse Consultant, and V2, Director of Nursing (DON), were notified of the Immediate Jeopardy on 6/20/25 at :4:05 PM. On 6/25/25, the surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2025-01-22 · tag F0600 — failed to protect residents from abuse and neglect — widespread
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure 1 of 4 residents (R2) was protected from another resident with known sexually inappropriate behaviors resulting in the sexual abuse of R2. This failure has the potential to affect all 123 residents residing at the facility. The Immediate Jeopardy began on 01/07/25 at 2:12 PM, when R3 was admitted back into the facility and the facility failed to initiation a plan of care and interventions to address how residents would be kept safe and free from sexual abuse, resulting in R2 being sexually abused by R3. V2, Director of Nursing (DON) and V7, Minimum Data Set (MDS) Coordinator were notified of the Immediate Jeopardy on 01/17/25 at 09:36 AM. The Immediacy was removed on 01/17/25, but noncompliance remains at Level II due to time needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 01/15/25 at 2:00 PM, The Illinois Department of Public Health (IDPH) Detailed Incident Summary of the 1/10/25 incident…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2025-01-09 · 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 monitor and supervise 1 of 3 residents (R4) reviewed for elopement in a sample of 10. This failure resulted in R4 leaving the facility unattended, on 12/20/2024 from 2:00 AM to 3:30 AM, falling outside the facility, sustaining multiple abrasions to both lower extremities, a dislocated left wrist, and a laceration to R4's forehead and left cheek that required sutures. The Immediate Jeopardy began on 12/20/2024 when R4 eloped from the facility without staff knowledge. R4 was last seen in the facility on 12/20/2024 2:00 AM and was found outside the facility on the ground. Due to R4 physical and cognitive vulnerabilities, R4 had the likelihood of serious harm and injury when R4 eloped. V1, Administrator, and V30, Regional Clinical Nurse, were notified of the Immediate Jeopardy on 1/3/2025 at 2:50 PM. Surveyors confirmed by observation, record review, and interview, the Immediate Jeopardy was removed 1/7/2025 but noncompliance remains at Level Two because…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2023-11-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to monitor/assess and treat a wound and monitor the resident's overall condition related to wound infection for 1 of 3 residents (R4) reviewed for wounds in the sample of 9. This failure resulted in R4 developing a swollen leg on [DATE] with V22, Physician/Medical Director, prescribing an antibiotic on [DATE] which was not given for 5 days. There was no documented monitoring of R4's leg until [DATE] at which time, R4 had an infected necrotic left leg wound measuring 20 centimeters (cm) by (x) 12 cm x .6 cm and a necrotic left foot wound measuring 10 cm x 8 cm x diameter 0.9 cm requiring surgical debridement by V31, Wound Physician. Subsequently, there was no monitoring of R4's medical condition while receiving antibiotics for his wound infection including vital signs from 10/2 through [DATE]. On [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia. The Immediate Jeopardy began on [DATE] when R4…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-03-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 2. R34's Face Sheet, undated, documents that R34 has diagnoses of difficulty in walking, other abnormalities of gait and mobility, muscle weakness, lack of coordination, syncope, and collapse. R34's Physician Order (PO) dated 04/04/22 documents other abnormalities of gait and mobility. R34's PO dated 07/28/21 documents other lack of coordination. R34's PO dated 07/28/21 documents muscle weakness (generalized). R34's Fall Risk Evaluation dated 12/14/22 documents a score of 17.0. R34's Care Plan dated 12/21/22 documents (R34) is at high risk for falls related to use of psychotropic medication, some visual loss and DX (diagnosis): Seizure Disorder and Syncope. 12/14/2022 - fall while going to restroom. R34's Care Plan Interventions document the following: 11/29/22 Education done with (R34) on taking his time while he is up walking. 12/14/22 Education to (R34) to wear non-skid socks when not wearing shoes. R34's Nurse's Note dated 11/29/22 at 6:53 PM documents Resident lost his balance and fell to his knees in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2026-06-11 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews, the facility failed to ensure that medication was ordered and available in a timely manner for 6 of 6 (R5, R58, R84, R77, R101, R113), residents in a sample of 42. This failure resulted in R84 not receiving his pain medication and experiencing increased and excruciating pain, R5 not receiving a muscle relaxer and experiencing phantom cramps and pain in left lower extremity amputation. It also resulted in R58 not receiving is clonazepam and experiencing increased anxiety and chest pain resulting in transportation to hospital. Findings include:1 .R84's Care Plan, dated 7/29/2025, documents that PAIN: Resident has an alteration in comfort Advanced Disease process, Chronic physical. It also documents 7/29/2025 Administer pain meds and treatments as ordered. R84's Minimum Data Set, dated [DATE], documents that R84 is cognitively intact. R84's Physician Order, dated 7/25/2026, documents Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-06-11 · 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 administer pain medications for 3 of 4 residents (R5, R84 and R101) reviewed for pain in the sample of 42. This failure resulted in R5 experiencing phantom pain, R84 experiencing excruciating pain in wrist and back, and R101's pain being elevated to a level 8 on a scale of 1-10 for 2 days. Findings include: 1 On 6/8/2026 at 10:27AM R101's wife stated her husband has not had his pain medication for 2 days and he needs it. R101 agreed he had not had his pain medication and needed it. R101's current face sheet documents a diagnosis in part of acute hematogenous osteomyelitis left ankle and foot, cellulitis of left lower limb, personal history of other malignant neoplasm of bronchus and lung. R101's medication administration record (MAR) dated June 2026 documents Hydrocodone-Acetaminophen oral tab 10-325mg (milligram); give one tablet every 6 hours as needed for pain with start date 6/4/2026. R101's MAR documents R101 did not receive Pain…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-06-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide a safe resident environment and protect residents from abuse for 1 of 10 residents (R2) reviewed for resident abuse in the sample of 10. The findings include: R2's admission Record, dated 6/2/26, documents R2 was originally admitted to the facility on [DATE] with diagnosis of Schizophrenia, Major depressive disorder, Anxiety disorder, Wernicke's Encephalopathy, Cocaine abuse, Hypertension (HTN), Hyperlipidemia, Falls, Anemia, and Sleep disorder. R2's Care Plan, dated 8/16/19, documents R2 has a diagnosis (DX): Schizophrenia. She is at risk for impaired social interaction, disturbed sensory perception, defensive coping and disturbed thought processes. Interventions: 1:1's with resident as needed and as resident requests, assist resident to an area that is calm, quiet and free of stimuli as much as possible if resident allows, resident is on enhanced supervision. R2's Care Plan, dated 9/1/19, documents R2 is at risk for abuse and/or…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-10-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents resided in a safe environment, free from actual and potential abuse. This failure resulted in R3 who has a diagnosis of Schizophrenia, Bipolar Disorder and Depression, experience physical abuse from a staff member, injury to left eye and feeling fear, anger, and ashamed. Findings include:R3's Care Plan, dated 7/31/2025, documents that R3 is at risk for abuse and/or neglect related to Self-Isolation, psychotropic medications, hallucination/delusions, history of compulsive behavior, history of verbal and physical aggression and DX: Schizophrenia, Bipolar Disorder and Depression. It also documents If resident becomes difficult during care, make sure resident is safe and walk away. Allow resident time to calm down, then reapproach. Keep resident safe from harm at all times. 10/5/25 CNA (Certified Nurse's Assistant) was sent home for allegation, investigation started, abuse coordinator made aware, BPD ([NAME] Police Department)…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-23 · 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 interview, observation, and record review, the facility failed to provide pain medication to 1 of 3 residents (R3) reviewed for pain control in the sample of 8. This failure resulted in R3 having excruciating pain and having trouble functioning during that time in pain. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus (DM), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection.R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). R3 has an alteration in comfort with interventions including administer pain meds and treatments as ordered, assess pain characteristics: duration, location, quality, encourage to report any pain, monitor for nonverbal indicators of pain (moaning, crying, grimacing, wincing), report any acute changes to Physician. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-07-23 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure 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, observations, and record review, the facility failed to provide an antibiotic for 1 of 1 resident (R3) reviewed for medication administration in the sample of 6. This failure resulted in R3 not receiving his antibiotic as ordered, his Vancomycin Trough levels subtherapeutic therefore not sufficient in treating R3's Methicillin Resistant Staphylococcus Aureus (MRSA) infection in his lungs. The Findings Include:R3's admission Record, dated 7/21/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Diabetes Mellitus Type 2 (DM2), Pneumonia, Bacteremia, and a Lung Abscess with Methicillin Resistant Staphylococcus Aureus (MRSA) infection.R3's Care Plan, dated 7/9/25, documents R3 Is Independent with Activities of Daily Living (ADLs). R3 has an alteration in comfort with interventions including administer pain meds and treatments as ordered, assess pain characteristics: duration, location, quality, encourage to report any pain, monitor for nonverbal indicators of pain (moaning,…

  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
• Actual harm · G2025-04-29 · 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 timely incontinent/colostomy care in 1 of 1 resident (R2) reviewed for ADL (Activities of Daily Living) care in the sample of 6. This failure resulted in R2 developing painful, red excoriation around his colostomy site extending down to the abdomen, perineal area and buttocks. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, R2's family member at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified Nurse's Assistant) came into the room, asked what…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-04-29 · tag F0691 — failed to provide colostomy / ostomy care — isolated
  Provide appropriate colostomy, urostomy, or ileostomy care/services 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 colostomy care to 1 of 1 resident (R2) reviewed for ostomy care in the sample of 6. This failure resulted in R2 developing painful, red excoriation around the colostomy site extending down to the abdomen and perineal area. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, R2's family member at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, no abdominal binder present, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified Nurse's Assistant) came into the room, asked what was needed and then left 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 before2025-04-29 · 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 identify pain and provide pain relief to 1 of 1 resident (R2) reviewed for pain management in the sample of 6. This failure resulted in R2 having pain and discomfort related to excoriation around his colostomy site extending down to the abdomen and perineal area and that is not being treated or recognized. Findings include: On 4/23/25 at 8:45 AM, R2 was observed in bed with V8, family member, at bedside. R2's colostomy site and abdomen were observed with V8. There was a towel covering R2's abdomen, no abdominal binder present, V8 removed the towel and R2's colostomy bag was about 3/4 full and was leaking moderate amounts of liquid stool onto R2's abdomen, down into R2's abdominal folds, perineal area and under R2's bottom. R2's abdomen was red and excoriated. R2 was stating don't touch it, it hurts, burns and was shaking, appearing to be apprehensive and in pain. On 4/23/25 at 8:55 AM, R2 turned his call light on, V9, CNA (Certified…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent physical abuse for 3 of 4 residents (R5, R6, R10) reviewed for Freedom from Abuse and Neglect in a sample of 16. This failure resulted in R6 acquiring a subarachnoid hemorrhage and left orbital wall fracture. Findings include: 1. R6's Face Sheet documented R6 was admitted to the facility on [DATE] with diagnosis of, in part, bipolar disorder, chronic obstructive pulmonary disease and dementia. R6's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact. R7's Face Sheet documented R7 was admitted to the facility on [DATE] with diagnosis of, in part, schizophrenia, bipolar disorder and dementia. R7's MDS dated [DATE] documented he was cognitively intact. Facility's Serious Injury Incident and Communicable Disease Report dated 3/21/25 documented, It was alleged that there was a resident to resident altercation between (R6) and (R7). Upon investigation, (R7) was in the bathroom when (R6) entered and stood 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-28 · 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 interviews, observations, and record reviews the facility failed to prevent development of additional pressure injuries for 1 of 3 residents, (R1) reviewed for treatment/services to prevent/heal pressure ulcers in a sample of 16. This failure resulted in R1 developing two new Stage 2 pressure injuries. Findings include: R1's Face Sheet, documented R1 was admitted to the facility on [DATE] with diagnosis of, in part, paranoid schizophrenia, pressure ulcer stage 3, and atherosclerotic heart disease. R1's Minimum Data Set (MDS) dated [DATE], documented he is moderately cognitively impaired and required partial/moderate assistance with toileting hygiene; substantial/maximal assistance with showering/bathing and all transfers; and partial/moderate assistance with rolling left to right in bed. R1's Care Plan dated 1/24/25 documented he is at risk for skin complications r/t (related to) psychotropic medications and impaired independence with activities of daily living functions. Stage 3 Pressure ulcer 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent abuse for 3 of 7 (R20, R30, R62) residents investigated for resident-to-resident abuse in a sample of 39. Findings include: 1. R20's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE]. R20's EMR dated 07/28/16 documents a diagnosis of Schizophrenia. R20's MDS (Minimum Data Set) dated 02/04/25 documents a BIMS (Brief Interview for Mental Status) score of 6 out of 15. The MDS documents that the resident has not exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or other behavioral symptoms not directed towards others. R20's Care Plan dated 9/27/23 documents (R20) has a history of aggressive, inappropriate, attentions-seeking and/or maladaptive behavior. The resident has a diagnosis of paranoid schizophrenia. 06/14/22 (R20) was verbally and physically aggressive towards a peer. 02/19/23 Got mad and was verbally aggressive…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-14 · 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 assess and document a head to toe skin assessment upon readmission to the facility for 1 (R44) of 1 resident reviewed for pressure wounds in the sample of 39. This failure resulted in the deterioration of the pressure ulcer from a stage II to a stage III. R44's Undated Face Sheet documents initial admission date 4/17/2020 diagnoses of spina bifida and pressure ulcer of sacral region unspecified stage. R44's Annual Minimum Data Set (MDS) dated [DATE] documents she is alert and no pressure ulcers, not at risk for pressure ulcers, no unhealed pressure ulcers. R44's Care Plan, addresses resident at risk for skin complications r/t (related to) skin spina bifida. Goal: area to right buttock will remain stable/heal. Interventions: assess and document progress of areas weekly, assist and encourage resident to turn and reposition every one to two hours and PRN (when needed) and skin assessment weekly. R44's Hospital Discharge Paperwork, dated…

  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 · G2024-11-21 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report verbal abuse allegations to Illinois Department of Public Health for 1 of 3 residents (R2) reviewed for abuse. This failure resulted in R2 becoming upset, crying, refusing medications and refusing to eat. Findings include: R2's Face Sheet which is undated documents that R2 was originally admitted to the facility on [DATE] with diagnosis of weakness, need for assistance with personal care, major depressive disorder, anxiety disorder, persistent mood disorder, borderline personality disorder, schizoaffective disorder, unspecified psychological disorder. R2's Minimum Data Set (MDS) dated [DATE] documented R2 is cognitively intact. R2's mood is often down with little pleasure in activities. She has impairment to bilateral upper extremities and uses a wheelchair for mobility. She requires touching assistance or verbal clues with eating. R2's Care Plan dated 9/23/2024 documented problems that R2 can be socially isolative when she is in a bad mood. The…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-21 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate verbal abuse allegations for 1 of 3 residents (R2) reviewed for abuse. This failure resulted in R2 becoming upset, crying, refusing medications and refusing to eat. Findings include: R2's Face Sheet which is undated documents that R2 was originally admitted to the facility on [DATE] with diagnosis of weakness, need for assistance with personal care, major depressive disorder, anxiety disorder, persistent mood disorder, borderline personality disorder, schizoaffective disorder, unspecified psychological disorder. R2's Minimum Data Set (MDS) dated [DATE] documented R2 is cognitively intact. On 11/20/2024 at 9:55 am, R2 stated she had gone to shock treatments (on 11/13/2024) and had come back to the facility feeling excited afterwards because she felt better by feeling more confident and feeling less prone to outbursts. At about 4:30 or 5:00 pm, R2 asked V9, Medical Records, if she could lie down and eat in her room because she was tired. V9…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to ensure wound treatments were consistently provided for 1 of 3 residents (R2) reviewed for wound care. This failure resulted in R2 requiring transfer to the hospital, maggots developing in R2's wound, a diagnosis of osteomyelitis and needing IV antibiotics therapy. Findings include: R2's face sheet, dated 8/28/24, documented R2 has diagnoses of unspecified open wound on right lower leg, osteomyelitis, local infection of the skin and subcutaneous tissue, type 2 diabetes, bipolar disorder, coronary angioplasty implant and graft, traumatic compartment syndrome of right lower extremity, hypertension, and depression. R2's MDS (Minimum Data Set), dated 7/29/24, documented R2 is cognitively intact. R2's MDS, dated [DATE], documented R2 has not exhibited any rejection of care behaviors. R2's MDS, dated [DATE], documented R2 has not exhibited any rejection of care behaviors. R2's weekly skin assessment of right lower leg wound, dated 8/14/24,…

  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 before2024-04-24 · 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 residents do not have access to chemicals for 1 of 3 residents (R3) reviewed for supervision to prevent accidents in the sample of 5. This failure resulted in R3 drinking a liquid containing bleach, being transported to the hospital for evaluation and medical treatment. R3, as a person with altered mental status and Schizophrenia would be afraid and apprehensive of being sent to the hospital. Findings include: R3's admission Record, not dated, documents R3 was admitted on [DATE] and lists Major Depressive Disorder, Recurrent, Mild Unspecified Severe Protein-Calorie Malnutrition, Catatonic Disorder Due to Known Physiological Condition, Unspecified Psychosis not due to a Substance or known, Mood Affective Disorder, Altered Mental Status, Undifferentiated Schizophrenia as diagnoses. R3's Care Plan, dated 4/26/23, documents that R3's memory is impaired, and he has difficulty with decision-making, insight, logic, planning, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2024-04-18 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on interview and record review, the facility failed to ensure residents were free from abuse for 9 of 25 residents (R30, R35, R36, R39, R50, R63, R64, R85 and R88) reviewed for abuse, in the sample of 59. This failure resulted in R30 biting R50 and R50 being treated for a human bite and seeing the wound nurse for treatment. This failure also resulted in R85 being thrown out of wheelchair by R39, and R39 attempting to smash R85's head with the wheelchair causing an abrasion to R85's left ear, upper left arm, and face. Findings include: 1.R30's Physician Order Sheet (POS) for February 2024 documented a diagnosis of Unspecified psychosis not due to a substance or known physiological condition, unspecified asthma, morbid obesity, hypertension, major depression disorder, anxiety disorder, Schizophrenia, legal blindness, and post-traumatic stress disorder. R30's Minimum Data Set (MDS), dated [DATE], documented that R30 was severely impaired for cognition for activities of daily living. R30 was able to walk…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-18 · 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 A. Based on observation, interview, and record review, the facility failed to ensure resident's coffee was served at temperatures that would not burn aresident for 1 of 12 residents (R30) reviewed for accidents in the sample of 59. This failure resulted in hot coffee being spilled on R30 and R30 sustaining burns to thigh and abdomen. Findings include: 1. R30's Physician Order Sheet (POS) for February 2024 documents diagnoses of unspecified psychosis not due to a substance or known physiological condition, unspecified asthma, morbid obesity, hypertension, major depression disorder, anxiety disorder, Schizophrenia, legal blindness, post-traumatic stress disorder. R30's POS has an order dated 3/12/2024 at 3:07 PM, Silvadene external cream 1%, apply to abdomen topically every day shift for blister. Clean with wound cleaner then apply Silvadene and cover with dry dressing daily until healed. Apply to abdomen topically every day shift to promote wound healing. R30's Minimum Data Set (MDS) dated [DATE] documents R30…

  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 before2024-04-18 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide interventions to address weight loss for 1of 9 residents (R108) reviewed for weight loss in the sample of 59. This failure resulted in R108 losing 45.5 pounds (#s), a 16.98% loss of body weight in less than 2 months. Findings include: R108's Face sheet documents R108's admission date of 2/15/2024 with diagnoses of Hemiplegia, Hemiparesis following Cerebral Vascular Accident, Weakness, Dysphagia, Gastronomy tube status. R108's hospital discharge records dated 2/15/2024 documents R108's discharge weight of 268 pounds (#s). R108's admission Observation dated 2/16/2024 documents Formula 250 milliliters every 6 hours. R108's order sheet dated 2/16/2024 documents Nepro at (@) 250 milliliters (ml) every 6 hours via gastric tube. Discontinued 4/11/2024. R108's Minimum Data Set, MDS, dated [DATE] documents R108 cognition is severely impaired. R108's MDS documents upper extremity left side impairment and is dependent on staff for all…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-11-09 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed notify the physician of changes related wound infections including failure to give medications and treatments as ordered for 1 of 3 residents (R4) reviewed for notification in the sample of 13. This failure resulted on [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia. Findings include: R4's [DATE] Physician Order Sheet, POS, documents R4 has diagnoses of Cerebral Infarction due to unspecified occlusion or stenosis of unspecified cerebral artery; Generalized anxiety disorder; Alcohol abuse, insomnia; Anemia; hyperlipidemia; Vitamin deficiency; Hypertension, Schizoaffective disorder; Major depression disorder, and other skin changes. R4's Care Plan with a Focus Area of Skin: documents, (R4) is at risk for skin complications related to Anemia, psychotropic medications. (R4) has no open areas to skin. Date [DATE]. (R4) has open areas, are to left lower leg and left dorsal foot dated, [DATE].…

  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
• Actual harm · Gcited before2023-11-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility neglected to ensure residents were receiving timely assessment, monitoring, and treatment to address wounds and wound infections for one of three residents (R4) reviewed for neglect in the sample of 13. This failure resulted in R4 not receiving an antibiotic as ordered on [DATE] which delayed treatment of an infection, not receiving ordered wound treatments, not having timely assessments, and monitoring of his left leg which resulted in the development of two large infected necrotic wounds, and not monitoring the overall condition of R4 during his treatment of the infection. On [DATE], R4 was sent to the hospital and admitted with sepsis and expired on [DATE] from septic shock and bacteremia. Findings include: The Abuse Policy 2022 documents The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods, and services by staff or mistreatment. The facility prohibits abuse, neglect,…

  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 · D2026-06-11 · 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 interview, observation, and record review the facility failed to maintain resident dignity while eating in the dining room for 3 of 25 residents (R12, R77, R126) reviewed for resident dignity in the sample of 42. The findings include: 1. R77's admission Record, dated 6/10/26, documents R77 was originally admitted to the facility on [DATE] with medical diagnosis of Traumatic Brain Injury (TBI). R77's Care Plan, dated 11/29/22, documents R77 has potential for weight fluctuation related to good intake of meals, and he receives a snack at HS (hours sleep) daily, but he has diagnosis of Type 2 diabetes mellitus (DM), psychosis, cocaine abuse and unspecified focal TBI which may affect his intakes and/or weight. Interventions: Provide diet as ordered, he does use weighted utensils, staff assist with meal set up and feeding as needed, monitor and encourage diet compliance as needed. It continues 3/6/24: R77 at nutritional risk as disease progresses: type 2 DM and Hypertension (HTN). 11/16/25: Has had weight…

  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 · E2026-05-14 · 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 dispose of expired medications on the medication cart when reviewed for pharmacy services in the sample of 9. This failure has the potential to affect all 29 residents residing on the 500 hall. Findings Include:On 5/13/26 at 10:20 AM, the 500-hall medications care was observed with the following expired medications noted: Oyster Shell Calcium with an expiration date of 12/11/23; Acetaminophen 325mg (milligrams) with an expiration date of 6/2025; Bisacodyl 5mg with an expiration date of 12/2024; Vitamin C 250mg with an expiration date of 3/2026; Vitamin B12 500mcg (micrograms) with an expiration date of 4/2026; Simethicone 125mg with an expiration date of 2/2026; Loperamide Hydrochloride Oral Solution 1mg/7.5ml (milliliter) with an expiration date of 10/2025; Aspirin 81mg with an expiration date of 3/2026. On 5/13/26 at 10:20 AM, V21, LPN (Licensed Practical Nurse), stated there probably are expired medications on the cart, the nurses don't always check them, and she has been off for three days and noticed…

  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 before2026-05-14 · 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 interview and record review, the Facility failed to provide adequate supervision for a resident with a history of substance abuse in 1 of 4 residents (R2) reviewed for accidents and hazards in the sample of 9.Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE]. R2's Minimum Data Set, dated [DATE] documented R2 was moderately cognitively impaired and dependent with mobility. R2's Initial Psychiatry Evaluation Progress Note dated 4/27/26 documents R2 has a history of opioid use disorder and stimulant use disorder. R2's Care Plan dated 5/12/26 does not address R2's history of substance abuse. R2's Progress Note dated 4/20/26 at 6:59 PM documents a pipe with white appearance was found in R2's bag and discarded. R2's family was not allowed to visit, per safety protocol. R2's Progress Note dated 5/3/25 at 8:35 AM documents alcohol was found at R2's bedside. R2's Progress Note dated 5/12/26 at 11:43 AM documents R2 was suspected of being under the influence. On 5/12/26 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 · Fcited before2026-04-13 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 maintain an effective pest control program related to bed bugs in the facility. This has the potential to affect all 123 residents residing in facility.Findings include:1. R8's Census, not dated, documents that R8 was admitted to room [ROOM NUMBER]C on 3/13/2026. R8 was then moved to room [ROOM NUMBER]A on 3/21/2026. R8 was moved to room [ROOM NUMBER]A on 3/23/2026. R8's Minimum Data Set (MDS), dated [DATE], documents that R8 moderately cognitively impaired.R8's psychiatry/med-management initial evaluation note, dated 3/16/2026 at 11:40 AM, documents that R8 is alert and oriented x3.R8's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 3/16/2026 at 10:47 PM, documents Braden Evaluation: Sensory Perception: No impairment. Moisture: Rarely moist. Activity: Walks frequently. Resident has No Limitation: Makes major and frequent changes in position. Nutrition: Excellent. Friction and shear: No apparent problem. SW - BRADEN…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-13 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to initiate Enhanced Barrier Precautions and provide personal protective equipment for 4 of 4 (R21, R23, R24, R25) residents reviewed for infection control in the sample list of 28.Findings include: 1 On 4/7/2026 at 3:15 PM V20, Infection Preventionist, provided a list of residents on Enhanced Barrier Precautions (EBP). R21 was not listed as requiring EBP.R21's Skin Issue note, dated 4/6/2026 at 2:58 PM, documents that R21 has Skin Issue: #001: New skin Issue. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: New: new wound. Wound was present on admission. Painful: No. Staged by: Wound care clinic. Length (cm): 4 Width (cm): 3 Depth (cm): 0.3 Undermining: No. Tunneling: No. Granulation: 80%. Slough: 20%. Exudate amount: Moderate. Exudate type: Purulent: indication of pus, typically thick, yellow, green, tan or brown. Odor after cleansing: Faint. Periwound: Attached. Surrounding tissue: Fragile. Surrounding tissue: Intact.…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent abuse for 1 (R3) of 9 residents reviewed for abuse in the sample of 9.Findings include:R2's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnosis including aphagia (difficulty communicating verbally) bipolar, mood disorder, hemiplegia right side and anxiety.R2's admission Minimum Data Set (MDS) dated [DATE] documents he is cognitively intact and exhibited no behaviors. R3's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including bipolar and personal history of other mental and behavioral disorders.R3's Quarterly MDS, dated [DATE] documents he is cognitively intact and exhibited no behaviors. R7's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including depression, alcohol and cocaine abuse, high blood pressure and malignant neoplasm of bronchus and lung.R7's admission MDS, dated [DATE]…

  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 · Dcited before2026-04-03 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to investigate abuse for 1 (R3) of 9 residents investigated for abuse in the sample of 9.Findings include:R3's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including bipolar and personal history of other mental and behavioral disorders.R3's Quarterly Minimum Data Set (MDS), dated [DATE] documents he is cognitively intact and exhibited no behaviors.R3's Hospital Medical Record, dated 3/21/2026 documents an allegation of sexual abuse. R3's Hospital Medical Record, dated 3/23/2026 documents patient (R3) stated, He raped me [AGE] years old red hair and white.The Facility's Long-Term Care Facility Serious Incident Initial Report, dated 3/25/2026 documents administrator was notified of a sexual abuse allegation via hospital paperwork. Final report dated, 3/31/2026 documents (R3), a [AGE] year-old male, whose diagnosis includes bipolar disorder, pancytopenia, history of other mental disorders…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-01-09 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  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 pest control services for bed bugs when reviewed for physical environment. This failure has the potential to affect all 107 residents residing in the facility.Findings Include:On 1/6/26 at 1:58 PM, room [ROOM NUMBER] was observed, no residents reside in this room. Approximately seven dead bed bugs were noted on a glue board, one live bed bug noted on the mattress by the door.On 1/8/26 at 8:40 AM, room [ROOM NUMBER] was observed, this room does not house any residents, one live bed bug observed on the baseboard and one live bed bug on the mattress sheet. On 1/8/26 at 8:43 AM, room [ROOM NUMBER] was observed, this room does not house any residents, several dead bed bugs observed on the baseboards.On 1/6/26 at 10:14 AM, V6, Maintenance Director, stated the facility has not had any residents with bed bugs for a while. V6 stated the facility sprays for bed bugs every Monday, Wednesday, and Friday. V6 stated the facility does…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-06-11 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, and record review the facility failed to maintain an effective pest control system to eradicate bed bugs. This has the potential to affect all 113 residents living in the facility. Findings include: On 6/6/2025 at 9:00AM R3 stated I did not see the bed bugs. The Certified Nursing Assistants, CNAs, woke me up and they sprayed the room, took the sheets off, and I don't know where I went. They were in my roommate's bed. I am just waiting for all clear to get back to my room. On 6/6/2025 at 12:00PM R4 stated he was out of his room in the night because the staff found bed bugs in his bed. R4 stated the staff bagged his items and he had a sponge bath. He was taken to another room for the night and is still not back in his room. He denied knowing he had bed bugs. On 6/6/2025 at 8:30AM V1, Administrator, stated I got a call last night that the staff had found bed bugs in a resident room. I told them to follow the procedures. They are to put the linens in bags and wash. They are to bag all the residents' belongings. The residents are to be showered. We had a pest control…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-11 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the Facility failed to pass medications according to physician's orders for 5 of 7 residents (R2, R6, R8, R9, R10) reviewed for medication in the sample of 12. Findings include: 1. R2's Minimum Data Set (MDS) dated [DATE] document she was cognitively intact for decision making of activities of daily living. R2's Physician Order Sheets (POS) for May 2025 documents diagnoses of schizoaffective disorder, bipolar type, secondary, unspecified psychosis not due to a substance or known cause, and major depression disorder. R2's May 2025 Medication Administration Record (MAR) document olanzapine oral tablet 20 mg (milligrams), give 1 tablet by mouth one time a day for schizoaffective disorder, 8 AM. Sertraline HCL oral tablet give 250 mg, one time a day for MDD (major depression disorder). On 6/7/2025 at 10:48 AM, R2 stated she had not received her 8:00 AM meds yet this morning. R2 stated the nurse was running late for some reason, but she was an agency nurse, and she is…

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

  Pharmacy Service 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

$821,641 in federal fines across 7 penalties. 2 Medicare payment denials on record.

• $57,460 — penalty dated 2025-10-16
• $159,478 — penalty dated 2025-03-14
• $152,095 — penalty dated 2025-01-09
• $29,510 — penalty dated 2024-11-21
• $37,700 — penalty dated 2024-08-16
• $192,836 — penalty dated 2024-04-18
• $192,562 — penalty dated 2023-10-18
• Medicare payment denial — starting 2025-04-08 for 128 days
• Medicare payment denial — starting 2024-05-16 for 56 days

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

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

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

About 96% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $233K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in IL