St Paul's Senior Community

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.

46.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 291 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 51.9% 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 104 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% 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 108 beds and averages 99.5 residents a day — about 92% occupied, or roughly 8 beds typically open. It runs fairly full. 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 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.32 hrs/resident/day on weekends vs 3.83 on weekdays — 13% thinner on weekends. RN hours go from 0.45 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% 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.

40 citations, most serious first. The 20 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · Jcited 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 Based on interview and record review the facility failed to ensure proper transfer techniques to prevent falls and injuries for one of 7 residents (R2) reviewed for supervision to prevent falls in the sample of 7. This failure resulted in an Immediate Jeopardy when V8, Certified Nurse's Aide (CNA) transferred R2 incorrectly causing R2 to sustain bilateral femur (thigh) fractures and expiring on 04/14/24. This past non-compliance occurred from 04/11/24 to 04/12/24. The Immediate Jeopardy began on 4/11/24, when V8 attempted to transfer R2 by herself, and R2 falling and sustaining bilateral femur fractures. On 4/17/24, at 2:17 PM, V1, Administrator, V25, Regional Corporation Nurse and V26, Director of Clinical Operations were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed, and the deficient practice was corrected, on 4/12/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R2's…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Immediate jeopardy · J2023-12-05 · 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 maintain residents' highest practicable physical well-being by assessing and providing timely care and treatment of fractures for 1 of 3 residents (R22) reviewed for quality of care in the sample of 43. This failure resulted in R22 not receiving timely care and treatment for three days after a fall. When R22 was sent to the hospital for treatment, it was identified that he had bilateral femur fractures and a dislocated knee. The Immediate Jeopardy began on 11/23/23 when R22 had a syncope episode during a transfer by V14, Certified Nurse's Aide (CNA) with a sit-to stand lift. The facility did not conduct an assessment after this incident to ensure the safest mode of transfer for R22. Again on 11/24/23, R22 had another syncope episode while being transferred with a sit to stand lift. On 11/26/23, after having pain throughout the day, R22 was sent to the hospital. R22's sustained severely displaced fracture of the right proximal femur shaft, a severely…

  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 before2023-12-05 · 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 interview and record review, the facility failed to assess for and provide safe transfer techniques to prevent falls/injury for 1 of 14 residents (R22) reviewed for safe transfer techniques to prevent injury/falls in the sample of 43. This failure resulted in an Immediate Jeopardy when the facility failed to reassess R22 for the safest mode of transfer after having syncope episodes while being transferred with a sit-to stand lift. R22 sustained severely displaced fracture of the right proximal femur shaft, severely comminuted distal left femoral fracture with displacement of the knee joint. R22 has had two surgeries, a blood transfusion and remains in the Intensive Care Unit (ICU). The Immediate Jeopardy began on 11/23/23 when R22 had a syncope episode during a transfer by V14, Certified Nurse's Aide (CNA) with a sit-to stand lift. The facility did not conduct an assessment after this incident to ensure the safest mode of transfer for R22. Again on 11/24/23, R22 had another syncope episode while…

  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 before2025-02-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure respiratory care needs met current standards of practice for 5 of 6 (R1, R2, R4, R5, R6) reviewed for respiratory care. This failure resulted in R1 experiencing chest pain and tightness, shortness of breath and decreased oxygen saturations after R1 did not receive ordered nebulizer treatments. Findings include: 1.R1 was admitted to the facility on [DATE] with diagnoses of, in part, acute on chronic congestive heart failure (CHF), lymphedema and chronic obstructive pulmonary disease (COPD). R1's Minimum Data Set (MDS) dated [DATE], documented R1 is cognitively intact, and is on oxygen therapy. R1's Care Plan dated 2/18/25 documented R1 has oxygen therapy related to shortness of breath (SOB); R1 has pneumonia, give medications as ordered, monitor/document for side effects and effectiveness; R1 has asthma related to COPD, give nebulizer treatments and oxygen therapy as ordered, monitor for signs and symptoms of impending asthma attack:…

  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 before2025-02-10 · 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 residents' pride and dignity for 3 of 5 residents (R1, R3, R5) reviewed for resident dignity in the sample of 5. This failure resulted in expressed feelings of embarrassment and frustration. The Findings Include: 1. R1's admission Record, dated 2/5/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Malignant Neoplasm of bronchus or lung, Hypertension (HTN), Morbid Obesity, Diverticulosis, Sleep Apnea, Nicotine Dependence, Lymphedema, Pulmonary HTN, Congestive Heart Disease (CHF), and Peripheral Vascular Disease (PVD). R1's Care Plan, dated 1/24/25, documents R1 has COPD: Interventions: Give aerosol or bronchodilators as ordered, give oxygen therapy as ordered by the physician, monitor for difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond endurance, monitor for signs/symptoms of acute respiratory insufficiency. It…

  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 before2024-06-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide complete and timely incontinent care using proper technique; and failed to perform hand hygiene and glove changes for 3 of 4 residents (R6, R7, R8) reviewed for incontinence care in the sample of 10. This failure resulted in R7 obtaining a Urinary Tract Infection, (UTI), and being placed on an Antibiotic. The findings include: 1. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE], with diagnoses of Hypertension, (HTN), Respiratory Failure, Atrial-Fibrillation, (A-Fib), Chronic Kidney Disease, (CKD)-stage 3, Type 2 Diabetic Mellitus, (DM), Congestive Heart Failure, (CHF), Cardiac pacemaker, Atherosclerotic Heart Disease, (ASHD), and Hyperlipidemia. R7's Care Plan, dated 3/7/24, documents R7 has bladder incontinence. Interventions: the resident uses disposable briefs. Change, establish voiding patterns, R7 is Incontinent: Check the resident and as required for incontinence, wash, rinse and dry perineum,…

  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 · G2024-03-08 · 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 and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents (R2) reviewed for medication errors in the sample of 13. This failure resulted in R2 having a drop in blood pressure requiring hospitalization, intravenous fluids, and blood pressure support medication. This past non-compliance occurred on 2/26/24. Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Supraventricular Tachycardia, Myocardial Infarction, Cognitive Communication Deficit, need for assistance with personal care, Hypertension, and Hypotension. R2's Care Plan dated 11/28/23 documents, (R2) has Hypertension. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (tachycardia) and effectiveness. The Care Plan also documents, (R2) is on diuretic therapy r/t (related to) hypertension. Many other medications may…

  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 · Past Non-Compliance
• Actual harm · Gcited before2023-12-21 · 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 implement fall interventions to prevent falls for 3 of 3 residents (R1, R2, R3) reviewed for falls in the sample of 3. This failure resulted in R1 sustaining a laceration to her left eye and R2 sustaining a left hip fracture. Findings include: 1. R1's Face Sheet, undated, documents R1 has a diagnosis of Dementia, Osteoporosis, Stage 3 Chronic Kidney Disease and Type 2 Diabetes. R1's MDS (Minimum Data Set), dated 10/23/23, documents R1 has severe cognitive impairment, is dependent with toileting, bed mobility and transfers and has a history of falls. R1's Care Plan, dated 7/1/22, documents R1 is at risk for falls with an intervention, dated 12/4/23, not to leave R1 in her room unattended. R1's Fall Risk Assessment, dated 9/24/23, documents R1 is at high risk for falls. R1's Progress Note, dated 12/3/23 at 8:16 PM, documents resident fell out of her reclining wheelchair around 6:55 PM. The aide stated that she stepped out of the room to go…

  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 · G2023-12-05 · 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/neglected to prevent abuse/neglect for 4 of 5 residents (R22, R29, R53, R69) reviewed for abuse/neglect in the sample of 43. This failure resulted in R22 not being assessed timely and provided care and treatment after sustaining a fall that resulted in two fractured femurs and a dislocated knee. This failure also resulted in R53 being abused by an employee, with bruising, bleeding, and pain to her lower leg. Findings Include: 1. R22's Face Sheet, undated, documents R22 has the following diagnoses: Rheumatoid Arthritis, Weakness, Bilateral Osteoarthritis of the Knees and Abnormalities of Gait and Mobility. R22's Minimum Data Set (MDS), dated [DATE], documents R22 is cognitively intact and is dependent with transfers. R22's Care Plan, dated 8/17/23, documents R22 is at risk for falls. R22's Progress Note, dated 11/23/23 at 8:30 PM, documents R22 was being assisted to bed with two Certified Nursing Assistants, CNAs, per sit to stand mechanical lift, staff…

  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 before2022-12-07 · 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 assess and monitor pressure ulcers, ensure pressure ulcer treatments/services are administered per standards of practice and orders are administered per physician's orders (PO) for 1 of 7 residents (R8) reviewed for pressure ulcers in the sample of 40. This failure resulted in R8's unstageable pressure ulcer to right buttocks/thigh worsening and becoming infected. Findings include: R8's Face Sheet documents R8 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region: Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling) pressure ulcer, moderate protein-calorie malnutrition, Alzheimer's disease, muscle weakness, unspecified abnormalities of gait (ambulation) and mobility, and need for assistance with personal care.…

  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 · Ecited before2026-06-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination for 4 of 6 residents (R10, R11, R13, and R14) reviewed for food safety in the sample of 16.On 6/15/2026 at 11:50 PM, R11 stated the food was not always hot and they have complained about it, but it is still an issue. On 6/15/2026 at 11:54 PM, R13 stated her food is cold. They really need to make sure the food stays warm. This has been going on for a while now. I am not a big fan of pork, and we sure do have a lot of pork on the menu. On 6/15/2026 at 11:55 PM, R14 stated the food is not always hot and they have complained, and it is still not getting better. On 6/15/2026 at 11:58 PM, R10 stated the food is hit and miss, and it is cold more often than it is hot. On 6/15/2026 at 12:01 PM, V42, Dietary Aid was in the kitchenette dining area on the second floor, and she was taking temperatures from the stove. After taking the temperature of each item she did not record any temperatures in the book. V12 did not sanitize between…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-27 · 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

  Based on observation, interview, and record review, the facility failed to provided timely turning/repositioning and incontinent care to prevent pressure ulcers/injuries from worsening or developing new pressure ulcers/injuries for 1 of 4 residents (R50) reviewed for pressure ulcers in a sample of 47. Findings Include: R50's Face Sheet, documents that she has diagnoses of but not limited to primary osteoarthritis of right and left hand, pressure ulcer of sacral region, stage 4, and peripheral vascular disease. R50's Minimum Data Set (MDS), documents that R50 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 13 out of 15 and she is dependent on staff for all her activities of daily living (ADLs). R50 is always incontinent of bowel and bladder. R50s, Care Plan, documents that R50 has impairment to skin integrity related to (r/t) pressure injury to coccyx r/t pain, bladder incontinence, decreased mobility and poor circulation. R50 refuses repositing at times. Interventions include but are not limited to administer treatments as ordered and monitor for…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-12 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to serve food at palatable temperatures for 5 of 7 residents (R1, R6, R7, R8, R9) reviewed for Food and Nutrition Services in a sample of 13. Findings include:1.R1's Facesheet documented he was admitted to the facility on [DATE]. 2.R6's Facesheet documented he was admitted to the facility on [DATE].3.R7's Facesheet documented he was admitted to the facility on [DATE].4. R8's Facesheet documented he was admitted to the facility on [DATE].5.R9's Facesheet documented he was admitted to the facility on [DATE].On 3/9/26 at 11:22 AM, V3 (dietary director) stated they are serving turkey wraps with sweet potato fries and mixed vegetables with pudding for dessert. V3 stated they temped all the wraps prior to putting them in the coolers and they will be re-temped once they get to the floors. V3 calibrated this surveyor's thermometer to be 32.5 degrees and will subtract 0.5 from all findings. At 11:47 AM, the turkey wraps temped at 49.8 degrees and V3…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-09 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the Facility failed to ensure food served was appetizing and at a palatable temperature for 1 of 3 residents (R4) reviewed for food and nutritional services in the sample of 6.Findings include: 1-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with a diagnosis of paraplegia. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was cognitively intact and was independent with eating. R4's Diet Order dated 3/19/25 documented R4 was on a carbohydrate controlled diet. On 1/6/26 at 10:30 AM, R4 stated the food is always cold and lacks flavor. On 1/6/25 at 12:41 PM, a test tray was conducted using a metal calibrated thermometer after the last resident tray was served. The beef tacos measured 110 Fahrenheit (F), the broccoli measured 107 F, and the rice measured 101 F. The broccoli was mushy and light green in color. The Facility's Resident Council Meeting Minutes dated 11/28/25 document cold food as an issue/concern. The Facility's Resident…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-25 · 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 ensure 2 of 4 residents (R3, R5) reviewed for resident rights were treated with dignity and respect by allowing staff to use personal cell phones excessively during work hours in the sample of 5. Findings include:On 11/21/25 at 2:19 PM, V6, Certified Nursing Assistant (CNA), was sitting at a table in the 1 South Dining Room looking at a cell phone.On 11/22/25 at 5:20 AM, V15, Licensed Practical Nurse (LPN), was sitting at the 1 South Nurse's Station looking at a cell phone.On 11/22/25 at 5:25 AM, V16, CNA, was sitting at a table in the 1 South Dining Room looking at a cell phone.1-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including age related physical debility and muscle wasting and atrophy.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was moderately cognitively impaired.On 11/21/25 at 11:00 AM, R3 stated staff are frequently on their cell phones at work.2-R5's Face Sheet documents R5 was…

  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 before2025-11-25 · tag F0803 — failed to meet residents' dietary needs — isolated
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the Facility failed to follow its approved menu for 2 of 4 residents (R2, R3) reviewed for dietary services in the sample of 5. Findings include:1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease.R2's Diet Order dated 10/16/25 documents R2 is on a mechanical soft diet.The Facility's Mechanical Soft Menu for 11/21/25 documents ground sausage links will be served at Breakfast.R2's 11/21/25 Meal Ticket for Breakfast documents ground sausage will be served. On 11/21/25 at 8:51 AM, V5, Dietary Aid, began plating food for breakfast service.On 11/21/25 at 9:05 AM, V3, Assistant Director of Nursing (ADON), served R2 breakfast in the 1-South Dining Room. There were cubes of a white colored meat on the plate that were approximately one-half inch in size.On 11/21/25 at 9:07 AM, V5 stated she would not know what kind of meat was on R2's plate.On 11/21/25 at 9:10 AM, V6, Certified Nursing Assistant (CNA), was…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-25 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to provide meals at palatable temperatures for 1 of 4 residents (R3) reviewed for food and nutritional services in the sample of 5.Findings include:1-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including age related physical debility and muscle wasting and atrophy.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was moderately cognitively impaired.R3's Diet Order dated 2/21/25 documents R3 is on a carbohydrate controlled, no added salt diet.On 11/21/25 at 11:00 AM, R3 stated sometimes the food is served cold.The Facility's Resident Council Meeting Minutes dated 10/24/25 document cold food as an issue/concern.On 11/25/25 at 8:27 AM, V2, Director of Nursing (DON), stated the food should consistently be served hot.The Facility's Undated Monitoring Food Temperatures for Meal Service Policy documents food temperatures will be monitored daily to prevent foodborne illness and ensure foods are served at palatable…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-17 · tag F0726 — failed to have competent, trained nursing staff — isolated
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure nurse aids had the skills and competencies to care for 1 of 3 residents with urinary catheters (R2) in the sample of 3.Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including paraplegia and neuromuscular dysfunction of bladder.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was independent with cognitive skills for daily decision making, required partial assistance with rolling from side to side, was dependent for transfer, and had indwelling catheter.R2's Physician Order dated 8/27/25 documents R2 has indwelling urinary catheter with diagnosis of neurogenic bladder.R2's Care Plan initiated 6/3/24 documents R2 has a catheter related to neuromuscular dysfunction of the bladder and will remain free from catheter-related trauma.R2's Progress Note by V7, Registered Nurse, on 9/10/25 at 5:31 PM documents R2 stated V4 Certified Nursing Assistant (CNA) pulled on his catheter. The catheter…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-05 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the Facility failed to provide appetizing food at palatable temperatures for 3 of 5 residents (R1, R2, R5) reviewed for food and nutrition services in the sample of 5.Findings Include:1- R1's Face Sheet documents he was admitted to the facility on [DATE] with diagnoses including gastric ulcer, end stage renal disease, and muscle wasting and atrophy.R1's 8/15/25 Diet Order documents liberal renal precautions; no orange juice or bananas; limit potatoes and tomatoes; provide double protein portions three times daily; restrict fluid to 1500 mL (milliliter) in 24 hours.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact.On 9/4/25 at 9:20 AM, R1 stated the food is not good and is always cold.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including stage 3 sacral pressure ulcer, burns involving 50-59% of body surface, dependence on renal dialysis, and muscle wasting and atrophy.R2's 8/12/25 Diet Order…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-05 · tag F0806 — failed to honor food preferences — isolated
  Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
  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 always available alternative options were available for 2 of 5 residents (R2, R5) reviewed for food and nutrition services in the sample of 5.1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including stage 3 sacral pressure ulcer, burns involving 50-59% of body surface, dependence on renal dialysis, and muscle wasting and atrophy.R2's 8/12/25 Diet Order documents renal diet; no orange juice, oranges, bananas, or milk; limit tomatoes and potatoes to one meal per day.R2's MDS dated [DATE] documented R2 was cognitively intact. On 9/4/25 at 9:45 AM, R2 stated the Facility has an alternative menu, but is always told they do not have the items he requests.2-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including unspecified pressure ulcer of sacral region, muscle wasting and atrophy, and need for assistance with personal care.R5's 11/14/24 Physician Order documents pureed diet…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“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

$227,658 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $83,317 — penalty dated 2025-01-17
• $54,665 — penalty dated 2024-06-12
• $16,801 — penalty dated 2024-04-18
• $12,035 — penalty dated 2024-03-08
• $60,840 — penalty dated 2023-12-05
• Medicare payment denial — starting 2025-03-12 for 23 days

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

Part of a chain

This home belongs to TUTERA SENIOR LIVING & HEALTH CARE — 25 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

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

Follow the money — this home’s finances

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

This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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