Westminster Village
2025 East Lincoln Street, Bloomington, IL 61701 · Non profit - Corporation · 48 certified beds · (309) 663-6474 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,149 in federal fines (most recent 2024-03-26)
- its payroll-based staffing score sits well above its independent inspection score
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
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
| 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 held steady at 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 | 15.7% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.5% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 4.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 6.9% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 21.1% | 54.2% | 6.5% | better 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 | 4.4% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 32.7% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.3% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.5% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.5% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.9% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 26.8% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.3% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.36 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.77 | 2.22 | 1.80 | better |
‡ 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.
45.7% 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 131 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 53.6% 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 112 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 0.61 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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 | 45.7%CMS range 36.0–54.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.2%CMS range 5.4–12.6 | 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 | 53.6% | 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 | 37.5% | 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 | 37.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.0% | 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 | 6.0%CMS range 3.4–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.66 | 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 48 beds and averages 41.4 residents a day — about 86% occupied, or roughly 7 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 4.20 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.29 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.68 is at or above 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 3.63 hrs/resident/day on weekends vs 4.43 on weekdays — 18% thinner on weekends. RN hours go from 1.45 to 0.87 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2024-04-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two (R5, R21) of two residents reviewed for nutrition in the sample list of 31. These failures resulted in R5 experiencing a severe weight loss of 16.65% (percent) in six months and R21 experiencing a 15.6% severe weight loss in two months. Findings include: The facility's Nutrition (Impaired)/Unplanned Weight Loss- Clinical Protocol dated September 2017 documents the physician will be notified of significant weight loss including persistent changes in baseline appetite/food intake, and the physician will help identify medical conditions that may cause the weight change and will consider if any additional diagnostic testing is indicated. This policy documents the staff and physician will identify and implement…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to utilize the safest assistive devices for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in (R1) slipping from a sit to stand lift and sustaining a dislocated shoulder requiring closed reduction. Findings Include: 1. R1's Care Plan updated 3/5/24 includes the following diagnoses: Fall, Chronic kidney Disease Type III, Congestive Heart Failure, Muscle Weakness, Difficulty Walking, Unsteadiness on Feet, Abnormal Gait, Lack of Coordination, and Abnormal Postures. This Care Plan documents R1 is High Risk for Falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired, has functional limitations to all four extremities, uses a manual wheelchair and is totally dependent to roll wheelchair 150 Feet. This MDS also documents R1 is dependent for Sit to Stand, Toilet Transfer, and Toilet hygiene. R1's Care Profile Audit Report printed 3/26/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 Failures at this level required more than one deficient practice statement. A. Based on observation and interview, the facility failed to maintain the hot water supply in resident bathrooms and showers in safe operating temperatures. This failure affects seven residents (R3, R11, R13, R36, R47, R48, and R52) out of eleven reviewed for water temperatures on the sample list of 25. B. Based on observation, interview, and record review the facility failed to provide adequate supervision for one of three residents (R8) reviewed for wandering on the sample list of 25. Findings include: a. On 05/26/26 at 12:45 PM, while checking a random sample of the water temperatures in resident bathroom hand sinks utilizing an Illinois Department of Public Health digital automatically calibrating thermometer, the hand sink water temperature in room [ROOM NUMBER] was 120.9 degrees Fahrenheit (F). The water temperature in the hand sink in room [ROOM NUMBER] was 123.0 F. The hand sink water temperature in room [ROOM NUMBER] was 116.9…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-29 · 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 resident's rights to be free from resident to resident physical abuse. This failure affects two of three residents (R8, R9) reviewed for abuse on the sample list of 25. Findings Include: The facility's Abuse Prevention, Reporting, and Investigation Policy revised May 2026 documents the facility prohibits and is committed to preventing abuse involving any resident. Abuse is the willful infliction of injury. Physical abuse includes hitting, slapping, rough handling or unnecessary force. It is any intentional physical action that causes or could cause harm. R8's Care Plan dated 5/7/26 documents R8 is diagnosed with Alzheimer's Disease. R8 forgets safety concerns and will walk in his room and hallway without assistance. R8 has a history of wandering. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. R8 has physical behavioral symptoms directed towards others such as hitting, kicking, pushing, and grabbing. These…
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 before2026-04-23 · 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 observation, interviews, and record review, the facility failed to ensure physician-ordered daily weights were obtained and documented for two (R1 and R4) of the four residents reviewed for edema in a total sample of 10 residents.Findings include:1. R4's Progress note, dated 2/28/2026, documents that R4 discharged from the facility on 2/28/26. R4's Minimum Data Set (MDS), dated [DATE], documents R4 had an active diagnosis of heart failure.R4's Physician Order Summary Report, dated 2/20/2026, documents an order for a daily weight related to history of congestive heart failure (CHF).R4's Medication Administration Record, dated February 2026, documents that no weights were obtained or documented on 2/20/2026, 2/22/2026, 2/23/2026, and 2/24/2026.R4's nursing note, dated 2/28/2026, documented that R4 was observed with an increase in shortness of breath and increased swelling. It also documented that R4 was transferred to the hospital on this date.R4's undated Weight Summary documents that R4's weight on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-31 · 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
Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment for a resident on enhanced barrier precautions for 1 of 3 residents (R4) reviewed for infection control in the sample of 3.The findings include:R4's Order Summary Report dated 3/31/26 showed an order for enhanced barrier precautions for a peripherally inserted central catheter (PICC). The order had a start date of 3/26/26.On 3/31/26 at 11:12 AM, there was an enhanced barrier precaution sign on R4's bathroom door. The sign indicated that staff must wear gloves and a gown with device care and use.On 3/31/26 at 11:12 AM, V16 (Registered Nurse) was in R4's room. V16 was handling R4's PICC. V16 had on gloves but no gown. V16 said she was disconnecting R4 from his antibiotic. On 3/31/26 at 12:47 PM, V7 (Infection Control Nurse) said enhanced barrier precautions are precautions to help limit infections. V7 said staff were to wear gloves and a gown when handling a PICC. The facility's Enhanced Barrier Precautions Protocol policy with a revised date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-04-10 · 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 — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to label opened prepared foods with the date and time in the refrigerator. This failure has the potential to affect all 90 residents who reside in the facility. Findings Include: The facility's midnight census as of 4/8/24 is documented as 90. On 4/08/24 at 9:00AM, [NAME] slaw, whipped topping, and sour cream were observed in the refrigerator not labeled with a date or the time in which they were opened. At this same time, (V21), Dietary Manager stated I can't say how long these items have been in the refrigerator since they are not labeled. I will discard them. Food items should definitely be labeled with the date and time opened before being placed in the refrigerator.
- Potential for harm · Ecited before2024-04-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to obtain orders for oxygen, failed to store, change, and label oxygen and nebulizer tubing in accordance with facility policy (R16, R19, R26) and failed to provide routine cleaning of a humidifier (R15). R15, R16, R19, R26 are four of five residents reviewed for respiratory care in the sample list of 31. Findings include: 1.) On 04/08/24 at 11:18 AM there was a humidifier on the table in R15's room. R15 stated R15 was unsure what the machine is used for. There is no documentation in R15's medical record that R15 uses a humidifier or routine cleaning/care of the humidifier. On 4/08/24 at 1:51 PM V13 Registered Nurse confirmed R15's humidifier and stated V13 is unsure how often it is used. V13 stated R15's family brought in the humidifier and provides care/maintenance for the machine. On 4/09/24 at 12:53 PM V2 Director of Nursing (DON) stated V2 provides a list of humidifiers to housekeeping staff to clean monthly. V2 stated V2 was unaware…
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 before2024-04-10 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to implement enhanced barrier precautions as recommended by the Centers for Disease Control and Prevention. This failure affects five (R31, R97, R149, R150, R33) of five residents reviewed for enhanced barrier precautions in the sample list of 31. Findings include: 1.) On 4/09/24 at 1:26 PM V11 and V15 Certified Nursing Assistants entered R31's room and provided urinary catheter care. V11 and V15 did not wear gowns during R31's care and there was no signage posted on R31's door to indicate enahanced barrier precautions (EBP) use when providing R31's cares. R31's Care Plan dated 2/19/24 documents antibiotics were ordered to treat a Urinary Tract Infection. This Care Plan documents R31 has an indwelling urinary catheter due to urinary retention and includes interventions for contact isolation due to colonization of MRSA (Methicillin Resistant Staphylococcus Aureus (multidrug resistant organism). On 4/10/24 at 2:30 PM V2 Director of Nursing/Infection Preventionist stated the facility does not have a policy for EBP…
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 · D2024-04-10 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 for the ability to self administer medications for three (R37, R97, R101) of three residents reviewed for self administration of medication in the sample list of 31. Findings include: 1.) On 4/08/24 at 10:04 AM there were bottles of saline nasal spray and artificial tears at R37's bedside and in R37's bathroom. R37's Minimum Data Set, dated [DATE] documents R37 has moderate cognitive impairment. R37's Order Summary dated 4/9/24 does not include orders for saline nasal spray or artificial tears. R37's medical record does not document orders to self administer medications or that medications may be kept at the bedside. There is no assessment of R37's ability to self administer medications. 2.) On 4/08/24 at 10:24 AM there were two tubes of Diclofenac (topical pain reliever) 1% on R97's night stand. R97 stated R97 was unsure about the medication use. 4/9/24 at 11:31 AM the Diclofenac tubes were on R97's night stand. R97's Brief…
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 · D2024-04-10 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to investigate an injury of unknown origin for one (R16) of three residents reviewed for accidents in the sample list of 31. Findings include: The facility's Abuse Policy dated June 2023 documents allegations or suspicions of abuse, neglect, mistreatment, misappropriation of resident property, or injuries of unknown origin will be reported to the facility's Administrator, Director of Nursing, or other designated staff. This policy documents injuries are considered of unknown source when the source of the injury was not observed or could not be explained by the resident and is suspicious due to the extent or location of the injury or number of injuries at one time or over time. This policy documents injuries of unknown source will be investigated within two hours of receipt of notification and the results of the investigation will be reported to the Illinois Department of Public Health within five days. R16's Nursing Note dated 3/14/2024 at 6:32 AM documents R16 fell and required the use of a full mechanical lift to transfer…
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 · D2024-04-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to conduct careplan meetings for one of one residents (R21) reviewed for careplan meetings in the sample list of 31. Findings include: On 4/08/24 at 12:41 PM R21 stated the facility does not have care plan meetings with R21 or R21's family. R21's medical record documents she admitted to the facility on [DATE] and Minimum Data Sets were completed on 12/18/23 and 2/16/24. On 4/09/24 at 10:25 AM, V8 Social Services Director (SSD) stated R21 last had a care plan meeting on 12/28/23 and residents have a care plan meeting every quarter. On 4/9/24 at 11:30 AM, V9 Assistant SSD stated V8 was still working on getting R21's care plan information and R21's care plan meeting was scheduled today for 4/11/24. On 4/9/24 at 2:35 PM, V10 Minimum Data Set (MDS)/Care Plan Coordinator stated R21 has not had a careplan meeting since 12/28/23 and V10 follows the MDS schedule to set up care plan meetings every 90 days. V10 stated V10 has 95 residents to keep track of and 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.
Show the remaining 16 citations
- Potential for harm · Dcited before2024-04-10 · 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 observation, interview, and record review the facility failed to document and follow up on a change in condition for one (R28) of 14 residents reviewed for change in condition in the sample list of 31. Findings include: On 4/08/24 at 10:54 AM R28 stated R28 has a right elbow goose egg and swelling that started about three weeks ago and R28 has told the nurses about it. R28 stated the nurses told R28 that R28 needed to see the doctor, but R28 has not yet seen R28's physician to evaluate R28's elbow. R28's right elbow had swelling approximately the size of a golf ball. R28's Minimum Data Set, dated [DATE] documents R28 is cognitively intact. There is no documentation in R28's medical record of R28's right elbow swelling or that R28 has been evaluated for this complaint. On 4/09/24 at 3:19 PM V25 Registered Nurse stated V25 noticed R28's swollen right elbow last Thursday (4/4/24) when R28 complained about it. V25 described the swelling as soft fluid, and similar to gout. V25 stated V25 left a note 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.
- Potential for harm · D2024-04-10 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to complete a comprehensive wound assessment for new pressure injuries for two residents (R149, R150) of three residents reviewed for pressure ulcers in a sample list of 31. Findings Include: 1. R150's Nursing admission History dated 3/15/24 at 6:08PM documents R150 was cognitively intact and required staff assistance for transfer and Activities of Daily Living (ADLs) and R150's skin was intact. R150's Minimum Data Set (MDS) dated [DATE] documents R150 has two Stage II pressure Ulcers. R150's Order Summary printed 4/10/24 at 4:03PM includes a physician's order originating 3/27/24 for Right buttock open area: Cleanse with Normal Saline, apply hydrocolloid every evening shift every 3 day(s). This order summary also documents a physician's order originating 4/9/24 for Left buttock open area: Cleanse with NS, apply skin prep around wound bed, apply hydrocolloid every evening shift every 3 day(s). There is no comprehensive wound assessment…
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 before2024-04-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure oxygen canisters were secure (R101), thoroughly investigate falls, and care plan and implement fall interventions (R5). R101 and R5 are two of three residents reviewed for accidents in the sample list of 31. Findings include: 1.) On 4/08/24 at 10:19 AM and 1:42 PM there were two unsecured, free standing, Oxygen cylinders at the end of the hall near R101's doorway. On 4/08/24 at 2:48 PM V2 Director of Nursing stated we have a room to store oxygen, we have liquid oxygen, and sometimes hospice delivers oxygen cylinders to the facility without notifying us. V2 stated oxygen cylinders should be secured. V2 observed the unsecured oxygen cylinders near R101's room and confirmed they were not stored appropriately. V2 stated the oxygen cylinders belong to R101 who was recently admitted to hospice, and hospice must have delivered the oxygen. V2 stated the cylinders will need to be placed in the oxygen storage room. The facility's Oxygen…
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 · D2024-04-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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
Based on observation, interview, and record review the facility failed to perform complete urinary catheter care, failed to prevent cross contamination during urinary catheter care, and failed to maintain the urinary collection bag in a dignity bag and off the floor for three residents (R33, R31, R97) of four residents reviewed for catheter care in a sample list of 31 residents. Findings Include: 1. R33's Physician's Orders for 4/1/24 to 4/30/24 document a Physician's order for urinary catheter care daily and as needed. On 4/10/24 at 11:00 AM V22, Certified Nurse's Aide (CNA) and V23 Certified Nurse's Aide (CNA) proceeded to perform catheter care for R33. R33 was wearing a pull up style incontinence garment. R33 had a bowel movement prior to care. V23 retracted R33's foreskin and cleaned R33's penis from tip to base. V23 cleansed the catheter tubing from insertion site downward. Both CNAs turned R33 to the left side. V23 removed the incontinence brief and cleaned R33's gluteal cleft and buttocks. Both CNA's placed a clean incontinence brief on R33 and covered R33. Neither CNA…
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 · D2024-04-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 record review the facility failed to complete/accurately complete psychotropic medication assessments, quantify behaviors to justify the use of psychotropic medication, and attempt nonpharmacological interventions for behaviors for two residents (R14,R5) of five residents reviewed for psychotropic medications in a sample list of 31 residents. 1.) R5's Order Summary Report dated 4/10/24 documents R5 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Major Depressive Disorder, Delusional Disorder, and Paranoid Personality Disorder. This Order Summary documents orders for Buspirone HCL (hydrochloride) (antianxiety) 5 mg (milligrams) one table three times a day related to Anxiety Disorder and Major Depressive Disorder with a start date of 12/8/23, Escitalopram Oxalate (antidepressant) 10 mg every morning related to Anxiety Disorder and Major Depressive Disorder with a start date of 3/21/24 and Mirtazapine (antidepressant) 7.5 mg related to Major Depressive…
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 · D2024-04-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 documentation of immunization status, and offer/administer Pneumococcal and Influenza (Flu) Vaccines for three (R31,R21,R26) of five residents reviewed for immunizations in the sample list of 31. Findings include: The facility's Influenza and Pneumococcal Immunization policy dated April 2024 documents the facility will offer residents pneumonia vaccinations and Influenza vaccinations based on the Centers for Disease Control and Prevention (CDC) Guidelines, and the Nursing Department is responsible for ensuring residents receive the pneumonia and Influenza vaccine and documentation is completed. This policy documents that residents will be screened annually for Influenza vaccination during the months of October 1st (or as soon as its available for the season) - March 31st unless immunization is medically contraindicated or the resident has already been immunized during this time period. On admission all residents will be offered the appropriate…
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 · D2024-04-10 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to offer and administer COVID-19 vaccination boosters to two (R31, R21) of five residents reviewed for COVID-19 vaccinations in a sample list of 31 residents. Findings include: 1. R31's undated face sheet includes diagnoses of History of COVID-19, Hypertension, Metabolic Encephalopathy, Hypo-Osmolality and Hyponatremia. R31's Electronic Medical Record reviewed 4/10/24 documents R31 received a COVID-19 Vaccine on 5/3/2022, and R31 was admitted to the facility on [DATE]. R31's medical record does not document education was provided to R31 regarding COVID-19 vaccination, nor does it document a COVID-19 booster was offered or administered. 2. R21's undated face sheet includes diagnoses of Pneumonia, Anemia and Cerebral Infarction. R21's Electronic Medical Record reviewed 4/10/24 documents R21 was admitted to the facility on [DATE]. This record does not document that COVID-19 vaccinations were offered or given to R21, or of vaccine history/status. On 4/10/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-23 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to implement infection control measures to protect oxygen tubing from cross contamination for a resident isolated with a drug resistant infection. This failure affects one resident (R10) out of four reviewed for respiratory care on the sample list of 31. B. Based on interview and record review, the facility failed to develop a water management plan that included the required risk assessment, control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 36 residents in the facility. Findings include: a. On 6/20/23 at 10:36 am, there were posted signs on R10's room door to indicate R10 was being isolated with contact precautions requiring gown and gloves to be worn in the room. R10 was seated in a cushioned chair in R10's own room. R10's oxygen concentrator was operating at 2.5 liters per minute. R10 was receiving oxygen…
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 before2023-06-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain respiratory equipment in a sanitary manner according to facility policy, and failed to follow facility policy for documenting maintenance of respiratory equipment. This failure affects four residents (R7, R10, R21, and R24) out of four reviewed for respiratory care on the sample list of 31. Findings include: 1. On 6/20/23 at 10:36 am, R10 was seated in a cushioned chair in R10's own room. R10's oxygen concentrator was operating at 2.5 liters per minute. R10 was receiving oxygen therapy through nasal cannula prongs inserted directly into R10's nostrils. The nasal cannula tubing and humidifier bottle were not dated to indicate the most recent changing of the tubing and humidifier bottle, and there was no receptacle to contain the nasal cannula tubing when not in use. There was a nebulizer machine on the bedside bureau in R10's room with oxygen tubing attached and the tubing for the nebulizer was likewise undated to indicate when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-23 · tag F0757 — failed to avoid unnecessary drugs — patternEnsure 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 review resident's medication orders to prevent duplicate therapy and the potential for excess dosage for four of four residents (R135, R5, R13, R136) reviewed for duplicate medications in the sample list of 31. Findings include: The facility's admission Medication Regimen Review with a Revision date of 10/1/18 documents, An electronic medication regimen review (MRR) will be performed within 72 hours or an agreed upon timeframe of admission by a licensed pharmacist per written authorization from the facility. Significant medications issues identified by the consultant pharmacist during the admission Medication Regimen Review, must be communicated to the prescriber or designee and resolved by 11:59 P.M. the following day, per the IMPACT Act. Procedure 1. The consultant pharmacist will routinely access an electronic file to identify new admissions. 2. The consultant pharmacist will conduct an electronic comprehensive review of each patient's medication therapy. 7. The pharmacist's analysis of the medication regimen includes:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-06-23 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to document an open date on insulin when opened and failed to secure a controlled substance in a medication refrigerator for four of four residents (R15, R137, R21, R87) reviewed for medication storage and labeling in the sample list of 31. Findings include: The facility's Storage and Expiration Dating of Medications, Biologicals policy with a revision dated of 7/21/22 documents, 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has shortened expiration date once opened or opened. 5.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g. {example} needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-06-23 · 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 2. R185's Census (6/23/23) documents R185 was admitted to the facility 6/8/23. R185's Electronic Medical Record, in it's entirety as available at the time of review (6/20/23 at 3:46 pm), did not document any code status to direct staff what actions to take in a life saving situation involving R185. On 6/21/23 at 11:26 am, R185 stated, I have talked about this (life saving measures) with my kids. At my stage of life I would want them to try (to resuscitate) a little bit but I wouldn't want them to keep dragging it out for a long time. R185's Minimum Data Set, dated [DATE] documents R185 received a score of 14 out of a possible 15 during a Brief Interview for Mental Status (BIMS), rating R185 as cognitively intact. Based on interview and record review the facility failed to honor resident's right to choose to receive or decline treatments including life saving interventions by failing to incorporate the resident's choices regarding cardiopulmonary resuscitation into their medical record and plan of care according…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-10-14 · 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 prevent the potential for cross-contamination and foodborne illness to maintain a can opener and mixer in a safe sanitary condition These failures have the potential to affect all 34 residents residing in the facility. Findings include: 1. On 10/11/22 at 9:45 am initial tour with V5, Certified Dietary Manager/ Director of Dining Services (CDM) confirmed a commercial manual table top mounted can opener gears had a build up of dark brown grease-like substance with adhering metal fragments. V5, CDM stated That looks pretty bad. It is supposed to be cleaned after each use. It is obvious that didn't happen. 2. On 10/13/22 at 10:55 am V5, Certified Dietary Manager/Director of Dining Services (CDM) toured the kitchen. V5, CDM confirmed the free standing commercial size four foot tall mixer was clean and ready for use. The commercial mixer had an approximately six inch long, four inch diameter mixer attachment holder. The attachment holder placement was directly over the extra large multi-gallon mixing bowl. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-10-14 · 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 interview and record review, the facility failed to honor resident's right to choose to receive or decline treatments including life saving interventions by failing to accurately incorporate resident's choices regarding cardiopulmonary resuscitation into their medical record and plan of care according to the facility policy. This failure affects one of one resident (R81) reviewed for advanced directives on the sample list of 23. Findings include: The facility policy Advance Directives, admission Policy dated July 2022 documents the following: (The facility) recognizes an individual's right to formulate an advance directive and will use its best effort to inform its residents of this right. Procedure: 1. Upon admission, the resident or the appropriate surrogate decision maker as outlined by the Health Care Surrogate Act or Powers-of-Attorney, if resident is mentally incapacitated) will be given an informational packet which explains advance directives and the resident's right to formulate same. 2. Social…
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 · D2022-10-14 · 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 identify the type of dialysis access and provide monitoring or care to the dialysis access site for one of one resident (R8) reviewed for dialysis on the sample list of 23. Findings Include: R8's Hospital History and Physical dated 07/20/22 (five days prior to R8's admission) was provided to the facility and filed in resident paper chart documents R8 receives hemodialysis Tuesday, Thursday and Saturday. R8's Physician Order Summary Report Sheet (POS) dated 10/12/22 documents the following diagnoses list, on admission to the facility 7/25/22: End Stage Renal Disease, Dependence on Renal Dialysis, Long Term 'Current Use of Insulin, Type II Diabetes Mellitus with Unspecified Complications, Anemia Unspecified, and Primary Encounter for Orthe Orthopedic Aftercare. The same POS does not document a physician order for resident hemodyalysis treatments. The corresponding Medication Administration Record and Treatment Administration Record do not…
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.
- No harm found · C2023-06-23 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to develop their abuse prevention policy to include the required 2 hour time frame for reporting allegations of abuse the state survey agency (Illinois Department of Public Health). This failure has the potential to affect all 36 residents residing on the certified parts of the facility. Findings include: The facility policy Abuse Policy - (Facility Name) dated June 2023 documents, This facility will immediately (within 24 hours) report such instance, suspicion, or allegation of abuse, neglect, mistreatment, misappropriation of property, or injury of unknown source to the Illinois Department of Public Health. This statement is repeated Upon receiving a report of an instance, suspicion, or allegation of abuse, neglect, mistreatment, misappropriation of property, and injuries of an unknown source concerning a resident of (Facility Name), the Administrator or Director of Nursing will submit a facility incident report to IDPH (Illinois Department of Public Health) not more than 24 hours after receiving the report. This same…
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
$12,149 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $12,149 — penalty dated 2024-03-26
- Medicare payment denial — starting 2024-04-24 for 5 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ARMSTRONG, CARLOS | Individual | CORPORATE DIRECTOR | since 04/15/2021 |
| BEATY, CHAD | Individual | CORPORATE DIRECTOR | since 06/20/2024 |
| BUETTNER, CHRIS | Individual | CORPORATE DIRECTOR | since 06/18/2019 |
| CURTIS, SARAH | Individual | CORPORATE DIRECTOR | since 06/15/2017 |
| DEKEERSGIETER, MARK | Individual | CORPORATE DIRECTOR | since 06/20/2024 |
| FRERICHS, TROY | Individual | CORPORATE DIRECTOR | since 04/15/2021 |
| HALL, MONICA | Individual | CORPORATE DIRECTOR | since 05/15/2021 |
| HINCH, NATE | Individual | CORPORATE DIRECTOR | since 06/16/2022 |
| HOSEA, ARLENE | Individual | CORPORATE DIRECTOR | since 06/20/2024 |
| MCCLELLAN, STEPHANIE | Individual | CORPORATE DIRECTOR | since 02/27/2025 |
| SCHILL, KELVIN | Individual | CORPORATE DIRECTOR | since 02/20/2020 |
| TEICHMAN, CARL | Individual | CORPORATE DIRECTOR | since 08/20/2015 |
| YONT, GREG | Individual | CORPORATE DIRECTOR | since 08/17/2023 |
| RIEHLE, MATTHEW | Individual | CORPORATE OFFICER | since 02/14/2023 |
| WILLIAMS, KATIE | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 06/08/2015 |
| BAKER, CHRISTINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/10/2019 |
| LAU, DANIEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/08/2025 |
CMS files one row per role, so the 20 rows in the source record cover these 17 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.
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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Illinois Medicaid page for homes that do.
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 145400. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-10, 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.