Belvidere Health And Rehab
1701 5th Avenue, Belvidere, IL 61008 · For profit - Limited Liability company · 80 certified beds · (815) 547-5451 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (19% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.5% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.9% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.4% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 88.0% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 5.9% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.0% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.4% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.5% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.9% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.6% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 50.0% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 32.0% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.7% | 13.9% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.75 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.78 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 61.9% 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 21 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 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.5%CMS range 5.9–14.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 61.9% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 57.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.21 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 80 beds and averages 51.2 residents a day — about 64% occupied, or roughly 29 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 2.89 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.99 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 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 2.42 hrs/resident/day on weekends vs 3.09 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.10 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 19% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · D2025-11-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 assess and implement prevention interventions for 1 of 3 residents (R2) reviewed for pressure wounds in the sample of 3.The findings include: R2's Skin Impairment/Wound Evaluation dated 7/19/25 shows R2 has a Stage 2 Pressure Injury of his right buttock. R2's admission Record dated 9/30/25 shows R2's diagnoses include, but are not limited to, Type 2 diabetes mellitus, hypertension, and anemia. R2's current care plan provided by the facility does not show any skin alterations or wounds and no interventions to treat or prevent further wounds or worsening of existing wounds. R2's current Order Summary Report dated 9/30/25 shows an active order for dressings to the open area on R2's right buttock every other day and as needed. R2's Treatment Administration Records beginning 7/1/25 through 9/30/25 all show R2 has been receiving wound treatments beginning on 7/20/25 through 9/30/25 to his right buttock wound.On 9/30/25 at 10:09 AM, V6, Registered Nurse (RN), said R2 is back from his shower, and she is going to do…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-18 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 implement Enhanced Barrier Precautions (EBP) for 2 of 3 residents (R2 and R3) reviewed for infection control in the sample of 3. The findings include:R2's Skin Impairment/Wound Evaluation dated 7/19/25 shows R2 has a Stage 2 Pressure Injury of his right buttock. R2's admission Record dated 9/30/25 shows R2's diagnoses include, but are not limited to, Type 2 diabetes mellitus, hypertension, and anemia. R2's current Order Summary Report dated 9/30/25 shows an active order for dressings to the open area on R2's right buttock every other day and as needed. R2's Treatment Administration Records beginning 7/1/25 through 9/30/25 all show R2 has been receiving wound treatments beginning on 7/20/25 through 9/30/25 to his right buttock wound.R3's admission Record dated 9/30/25 shows she was admitted to the facility on [DATE]. The facility's Pressure Ulcer Tracking log dated 9/30/25 shows R3 was identified as having a Stage 2 left buttock pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-25 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
2. R41's Physician Order Sheet dated 6/25 show R41 has diagnosis of cerebral infarction hemiplegia and hemiparesis following stroke affecting right side. On 6/24/25 at 8:45 AM, during the initial tour, R41 was in bed with his right contracted arm towards his chest, his right hand with closed tight fist. There was no device noted to R41's right hand. On 6/24/25 at 10:17 AM, R41 was in bed. There was no device noted to R41's right contracted hand. V3 (Registered Nurse) who was with this surveyor said R41 was admitted with contracted right hand and had not noticed the resident with a splint. On 6/25/25 at 8:53 AM, V7 (R41's Niece) during a family interview said her main concerns were R41 being in bed most of the time, his contracted right hand, and that she wants R41 to have exercises or therapy. On 6/25/25 at 1:25 PM, V5 Restorative Nurse said R41 does not have a splint for his contracted right hand. A splint helps to prevent further decline of the contracted hand. R41's last Restorative Assessment was 6/14/24. The facility has no formal restorative program, assessments were done…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 identify a change in condition in a timely manner. This applies to 1 of 16 residents (R23) reviewed for quality of care in the sample of 16. The findings include: R23's face sheet shows she is a [AGE] year old female admitted on [DATE]. Her face sheet lists her diagnoses to include: peripheral vascular disease, chronic heart failure, non-ST elevation (NSTEMI) myocardial infarction (heart attack), atrial fibrillation, chronic kidney disease stage 3, hypertension, and muscle weakness. R23's progress notes dated 6/21/25 at 2:58 PM shows, pt (patient) c/o (complained of) not feeling well, refused breakfast, and lunch. Drank 240cc (cubic centimeter) of fluids at lunch, nothing for breakfast. T99.3 (temperature) Tylenol given at 1230 (12:30 PM) c/o shortness of breath, sats (oxygen saturation) 89% on ra (room air), applied oxygen at 2 liters per n/c (nasal cannula). 1430 (2:30 PM (2 hours later)) reassessed by 2 nurses, abdominal breathing noted and heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-25 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure a resident wasn't prescribed an unnecessary antibiotic. This applies to 1 of 6 residents (R23) reviewed for unnecessary medications in the sample of 16. The findings include: R23's progress notes show: -6/12/25- a UA (urine analysis) was ordered and going to be picked up from the laboratory on 6/13/25. -6/13/25- V14 Nurse Practitioner (NP) aware of failed attempt to collect urine on day shift. Lab not here to collect . -6/14/25- urine was collected and awaiting pick up by laboratory. -6/15/25- urine culture noted to be in fridge called laboratory and spoke [to someone who] stated she doesn't understand why specimen was not picked up and now it needed to be entered as STAT (right now) -6/16/25- V14 NP notified that lab did not pickup urine, DON (V2- Director of Nursing) also notified Urine to be sent to another lab in AM per NP. -6/16/25 continue to show: R23's urine specimen was collected and ready for pick up by laboratory. -6/17/25, R23's progress notes show, Nursing manager and writer contacted daughter to update…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-25 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to follow their antibiotic stewardship program to ensure residents weren't prescribed unnecessary antibiotics. This applies to 1 of 6 residents (R23) reviewed for unnecessary medications in the sample of 16. The findings include: R23's electronic medical record (EMR) shows, she was prescribed a antibiotic for a presumed UTI (urinary tract infection). The facility attempted to get a urinanalysis done but the urine specimen was never picked up by the laboratory. R23 remained on the antibiotic without knowing whether she had a indication for it. On 6/24/25 at 1:50 PM during the infection control interview V2 Director of Nursing (DON) stated, the nurses use the McGeer's (set of guidelines used to diagnose urinary tract infections (UTIs) in long-term care facilities) and a SBAR (Situation, Background, Assessment, and Recommendation) to help when determining whether a resident needs a antibiotic or not. She also monitors residents on antibiotics. This is part of the facility's antibiotic stewardship program. R23's EMR does not show…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 protect a resident (R2) from abuse. This applies to 1 of 3 residents reviewed for abuse in the sample of 9. The findings include: R1's electronic face sheet printed on 10/2424 showed R1 has diagnoses including but not limited to altered mental status, psychosis, and adjustment disorder with mixed anxiety and depressed mood. R1's facility assessment dated [DATE] showed R1 has mild cognitive impairment and experiences verbal behaviors directed towards others. R1's care plan dated 10/10/24 showed, (R1) demonstrates behavioral distress related to generalized anxiety disorder and adjustment disorder. Problems are manifested by exhibiting physical and verbal aggression. Triggers may include poor impulse control, not personally identifying the situation/environment; demonstrate mood lability, showing little ability to self-regulate anger/temper and mood state . R1's care plan dated 8/7/23 showed, (R1) has a behavior problem he asks staff for sexual favors,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-06-13 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure sufficient Certified Nursing Staffing from October through December of 2023. This has the potential to affect all residents residing in the facility. The findings include: The facility's document CMS form 671 dated 6/11/24 showed 53 residents residing in the facility. The facility's Facility assessment dated [DATE] showed under nursing services that the number of CNAs (Certified Nursing Assistants) on the evening shift should be 4. The facility's October 2023 CNA schedule showed on 10/7/23, 10/14/23, 10/15/23 10/21/23, 10/22/23, 10/28/23 and 10/29/23 there were 2.5 CNAs scheduled on the evening shift. The facility's November 2023 CNA schedule showed on 11/4/23, 11/12/23, 11/18/23, and 11/19/23 there were 2.5 CNAs scheduled on the evening shift and on 11/25/23 and 11/26/23 there were only 2 CNAs scheduled for the evening shift. The facility's December 2023 CNA schedule showed on 12/3/23, 12/9/23, 12/16/23, 12/17/23, ad 12/24/23 there were 2.5 CNAs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-13 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure multi-dose insulin pens were dated when opened and failed to dispose of an expired medication for 3 of 5 residents (R9, R22, R156) in the sample of 17 and 2 residents (R13, R33) out of the sample. The findings include: 1. R9's June 2024 order summary report showed an order start dated 4/16/24 for Basaglar Kwikpen (insulin) 30 units one time daily. R22's June 2024 order summary report showed an order start dated 3/25/24 for Fiasp Pen-Injector (insulin) four times a day per sliding scale. R156's June 2024 order summary report showed an order start dated 6/8/24 for Glargine Pen-Injector (insulin) 15 units in the morning. R13's June 2024 order summary report showed an order start dated 3/11/24 for Toujeo Pen-Injector (insulin) 15 units every 12 hours. R33's June 2024 order summary report showed an order start dated 3/2/23 for Lantus Pen-Injector (insulin) 40 units every 12 hours. On 6/12/24 at 7:53 AM, the 300-hall medication cart had five insulin pens in the top drawer. The pens were labeled with the names…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident had an order or care plan for advance directives for 1 of 1 residents (R156) reviewed for advance directives in the sample of 17. The findings include: R156's Facesheet printed 6/13/24 showed he was admitted on [DATE] with diagnoses to include, but no limited to: left arm fracture, atrial fibrillation, stage 4 CKD (chronic kidney disease), diabetes, dementia, CHF (congestive heart failure), dysphagia, and depression. This document showed R1 was admitted for m a local hospital. The Advance Directive portion of this document was blank (no information was entered). R156's Progress Note dated 6/1/24 showed he was R1 was a Full Code. R156's Physician Order Sheets did not contain an order for Advance Directives. R156's EMR (Electronic Medical Record) did not contain a scanned POLST (Practitioner Orders for Life-Sustaining Treatment). R156's Care Plan did not have address Advance Directives prior to 6/13/24 (after surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 7 citations
- Potential for harm · D2024-06-13 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was free of restraints for 1 of 1 residents (R156) reviewed for restraints in the sample of 17. The findings include: On 6/11/24 at 9:40 AM, R156 was lying in bed on his right side, curled up. R156 had a blue cast extending from his upper arm down to his hand, in a flexed position. The right side of R156's bed was pushed against the wall and the left side of his bed had a side rail pulled up. The side rail extended from R156's shoulder area to his ankles. R156 was facing the wall. The side rail was only able to be placed in the up and down position from someone outside of the bed. R156 would not be able to remove it himself. On 6/12/24 at 10:42 AM, R156 was lying on his right side in bed with the side rail pulled up. On 6/13/24 8:55 AM, R156 was in bed, lying on back with bent knees, facing the left side rail. R156 was rocking his knees, as if trying to sit up. R156's left arm in a blue cast and he was unable to use it to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 physician orders and interventions were in place for oxygen administration for 1 of 1 resident (R28) reviewed for oxygen in the sample of 17. The findings include: R28's face sheet printed on 6/12/24 showed diagnoses including but not limited to chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, and presence of cardiac pacemaker. R28's facility assessment dated [DATE] showed moderate cognitive impairment. On 6/11/24 at 7:56 AM, R28 was asleep in bed. Oxygen was running via a nasal cannula at 1.5 liters per minute. At 10:57 AM, R28 was seated on the edge of his bed and the oxygen tubing was next to him. The oxygen was still running at 1.5 liters per minute. R28 stated he wears the oxygen at night while he is sleeping to help with his breathing. R28 said he occasionally puts it on himself during the day if he is napping. On 6/12/24 at 9:42 AM, R28 was out of his room. The oxygen condenser was still…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis 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 ensure monitoring a resident on dialysis treatment, failed to ensure emergency equipment for dialysis was at bedside, and failed to care plan treatment for a dialysis patient for 1 of 1 resident (R3) reviewed for dialysis in the sample of 17. The findings include: On 6/11/24 at 7:01 AM, R3 was in her room lying in her bed. The local medical transportation company was in the hallway preparing to pick R3 up and transport her to dialysis treatment. R3's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include anoxic brain damage, Chronic Kidney Disease (Stage 4), end stage renal disease, hyperkalemia, acute kidney failure and Type 2 Diabetes. R3's facility assessment dated [DATE] showed she has no cognitive impairment and requires dialysis treatments. R3's Physician Order Sheet showed an order started 1/19/2024, Dialysis at [local dialysis treatment center], Tuesday/Thursday/Saturday at 8:30 AM . R3's Current…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-13 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
Based on observation, interview, and record review the facility failed to document the administration of a narcotic on the count sheet and failed to reconcile the count between shifts for 1 of 1 resident (R158) reviewed for pharmacy services outside the sample. The findings include: R158's June 2024 order summary report showed an order start dated 6/7/24 for: Tramadol HCl 50 milligrams oral tablet give 1 tablet by mouth every 6 hours for pain. On 6/12/24 at 7:58 AM, the 300-hall medication cart narcotics box was reviewed with V6 (Registered Nurse-day shift) present. R158's Tramadol card had 19 tablets remaining. The corresponding count sheet showed 20 tablets remaining. V6 stated she caught the miscount this morning when she started her AM shift. V6 said she did the shift change narcotic count with V10 (Registered Nurse-night shift) and realized three doses of the Tramadol had not been signed out on the previous shifts. V6 said V10 corrected the count sheet for the doses she had given. V6 said V9 (Licensed Practical Nurse-PM shift) had given the third dose and that was the one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-08-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the facility's ice machine was free of a black mold like substance. This has the potential to impact all 53 residents residing in the facility. The findings include: The CMS 672 Resident Census and Conditions of Residents form dated 8/7/23 shows the total number of residents within the facility is 53. On 8/9/2023 at 10:40AM, the facility's ice machine was observed to have black mold like spots on a plastic piece of the machine above the ice hopper full of ice. There was also a black mold like substance on a seal at the top of the ice hopper folding door. On 8/9/2023 at 10:50AM, V4 said the ice machine was the only ice machine in the building. V4 Dietary Manager said the ice machine was used for all the residents in the facility. V4 said maintenance staff are responsible for cleaning the ice machine. On 8/9/2023 at 11:02AM, V5 Maintenance used a paper towel to wipe the seal and plastic piece inside of the ice hopper with black mold like spots. A dark brown or black color appeared on the paper towel after…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-09 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow physical therapy recommendations for a resident with a contracture. This applies to 1 of 5 residents (R31) reviewed for restorative services in the sample of 15. The findings include: R31's electronic medical records show his diagnoses to include: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side and cerebral infarction. R31's physical therapy Discharge summary dated [DATE] shows, Discharge recommendations: .Right AFO (ankle foot orthoses) to prevent worsening of plantarflexion (foot/ankle) contracture. On August 7, 8 & 9th, 2023, R31 was observed sitting up in his wheelchair at various times throughout the survey. He was wearing a sling on his right arm. He did not have any other braces/splints on. His right foot had a mild contracture. On August 9, 2023 at 9:30 AM, R31 stated, he did not have a brace (AFO). He was never assessed for one. He would wear it if he had one to help…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-09 · tag F0697 — failed to manage pain — isolatedProvide 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 ensure a resident's pain was managed before providing care and changing the dressing on his wound. This applies to 1 of 15 residents (R24) reviewed for pain management in a sample of 15. The findings include: On 8/8/23 at 10:05 AM V6, V7, and V8 (CNAs) assisted R24 with his personal care by rolling him back and forth in the bed. With each roll R24 moaned with pain. V8 repeated over and over, I'm sorry, I'm sorry. R24 was asked if he was in pain and he stated, yeah. The CNAs continued by turning R24 and placed him onto his right side. V9(RN) entered the room to change the soiled dressing on R24's coccyx. V9 removed the old dressing and R24 yelled out with pain. V8 and V9 both told R24 that they were sorry. V9 cleaned the wound and R24 continued moaning with pain. When all care was completed R24 was positioned on his back and stated that his right leg was hurting. V6 looked at R24's leg, stated that is was positioned ok and covered R24 with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MARLEE ASSOCIATES | Organization | DIRECT OWNERSHIP INTEREST | since 07/19/2021 |
| TEPPER, JOSEPH | Individual | DIRECT OWNERSHIP INTEREST | since 07/19/2021 |
| TOPPER, AARON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 07/19/2021 |
| MICHALSEN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2015 |
| RYAN, MARGARET | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2013 |
CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 89% 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 $747K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146071. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.