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Westminster Village

2025 East Lincoln Street, Bloomington, IL 61701 · Non profit - Corporation · 48 certified beds · (309) 663-6474 Medicare only — no Medicaid

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$12,149 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent May 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, 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 (31) — 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 independent health-inspection rating is low (2/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 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 3 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

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1015 S Mercer Ave · (309) 662-4321 · Call to confirm hours
Pharmacy
1130 S Veterans Pkwy · (309) 661-1839 · Call to confirm hours
Grocery
2203 E Oakland Ave · (309) 663-4012 · Call to confirm hours
Park
1017 S Mercer Ave · (318) 792-6885 · Typically dawn to dusk
Place of worship
1006 Four Seasons Rd · (309) 820-1400

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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.7%13.4%15.4%typical
Long-stay residents who lose too much weight1.5%6.3%5.4%better
Long-stay residents with a catheter left in their bladder4.0%0.9%0.9%worse
Long-stay residents with a urinary tract infection6.9%1.5%2.0%worse
Long-stay residents with depressive symptoms21.1%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.4%3.1%3.3%worse
Long-stay residents whose ability to walk worsened32.7%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.3%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers3.8%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control30.5%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.5%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine97.9%63.1%79.4%better
Short-stay residents rehospitalized after admission26.8%26.1%22.6%worse
Short-stay residents with an outpatient ER visit6.3%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days0.362.021.67better
Long-stay outpatient ER visits per 1,000 resident days0.772.221.80better

‡ 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.

45.7%U.S. median 51.5%
Got home and stayed home
8.2%U.S. median 10.7%
Went back to hospital
53.6%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.30
Therapy hours / resident / day
0.29hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

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 0.53 therapist hours per resident per day in 2025Q4 — more than 85% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.7%CMS range 36.0–54.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.2%CMS range 5.4–12.610.7%Oct 2022–Sep 2024no 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 discharge53.6%56.6%Oct 2024–Sep 2025CMS 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 discharge37.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.5%50.0%Oct 2024–Sep 2025CMS 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 identified98.5%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.4–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.661.02Oct 2022–Sep 2024CMS 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

1.29
RN hours/ resident / day
0.24
LPN hours/ resident / day
2.68
Aide hours/ resident / day
4.20
Total nurse hours/ resident / day
0.87
RN hoursweekends
36.5%
Total nursing turnover
27.3%
RN turnover

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 3.71 hrs/resident/day on weekends vs 4.28 on weekdays — 13% thinner on weekends. RN hours go from 1.27 to 0.74 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

5 ↓
deficiencies at the latest standard inspection (2026-05-29)
8
at the previous standard inspection (2025-06-10)

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.

ABCDEFGHIJKL

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.

31 citations, most serious first. The 12 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · G2024-04-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-05-29 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to post notice of the availability of state agency survey results. This failure has the potential to affect all 43 residents in the facility.Findings include:On 5/27/26 at 10:05 a.m., during the resident council meeting, residents stated they were unaware of where the state agency survey results were located.On 5/28/26 at 9:15 a.m., the facility's survey results were in a file bin attached to the wall in a hallway containing staff offices. There was not a notice to designate the location of the survey results files.On 5/28/26 at 10:42 a.m., V1 Administrator confirmed there is no posting alerting residents and/or the public where to locate survey results. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/26/26 documents 43 residents reside in the facility.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-05-29 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview, the facility failed to post the daily staffing data in a prominent location that is accessible to residents, staff, and visitors. This failure has the potential to affect all 43 residents in the facility.Findings include:On 5/27/26 at 3:05 p.m., and on 5/28/26 at 8:59 a.m., this surveyor was unable to locate the daily staffing data posted anywhere in the facility.On 5/28/26 at 9:09 a.m., V2 Director of Nursing stated the daily staffing data is posted in a hard plastic holder on unit C/D nurses' station.On 5/28/26 at 9:12 a.m., V11 Registered Nurse was at the C/D nurses' station and stated the daily staffing data is usually in a plastic holder setting on the nurses' station counter. At this time, V11 located the daily staffing data sheet on a clipboard, behind the nurses' station underneath the daily assignment sheets. V11 stated, I think it [plastic holder] broke. We will have to get a new one.The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/26/26 documents 43 residents reside in the facility.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-05-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report an allegation of physical abuse to the State Survey Agency. 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. Allegations involving abuse must be reported to the state surveying agency and other required authorities no later than four hours after the allegation is made known. Investigation results must be reported to the agency within five working days in accordance with federal long-term care requirements. R8's Minimum Data Set, dated [DATE] documents R8 is severely cognitively impaired. R8's Behavior Note dated…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-23 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-31 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fdisputed · IDR2025-06-10 · tag F0620 — widespread
    Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
    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 the admissions contract did not waive potential facility liability for losses of residents' personal property. This failure affects all 42 residents in the facility. Findings include: The admission contract folder, provided by V1 Administrator, and reviewed on 6/9/25, included the following: The facility's Skilled Care Establishment Contract Summary documents (the facility) is not responsible for loss of property belonging to Resident due to theft or any other cause unless such loss is caused by the negligent or intentional acts of (the facility) or its employees or agents. The welcome letter with bullet points of condensed information from the contract summary, documents Should your resident's items be lost, please contact Social Services in order to make a report. (The facility) are not responsible for lost or damaged items. On 6/09/25 at 1:40 PM V1 Administrator stated lost or damaged items are replaced by the facility on a case by case basis. V1 stated items can be lost in a person's home and the facility is…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-10 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent further potential abuse by failing to remove an alleged perpetrator (V7 Certified Nursing Assistant (CNA)) from resident care. This failure affects eight (R140, R4, R35, R22, R142, R141, R18, R31) of eight residents reviewed for abuse in the sample list of 32. Findings include: The facility's Abuse Policy dated June 2024 documents If the instance, suspicion, or allegation involves a staff member, the staff member may be suspended, or re-assigned to a duty with no resident contact, pending the conclusion and results of the investigation. On 6/08/25 at 9:30 AM R140's right arm was in a sling and right lower leg/foot was in an orthotic boot. R140 stated R140 prefers not to have male caregivers, and the day after R140 admitted to the facility V7 CNA gave R140 a lecture on why R140 shouldn't be concerned with having male givers. R140 stated V7 said V7 didn't understand why women R140's age don't want male caregivers, since women have…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to document a root cause or obtain witness statements for fall investigations for four residents (R8,R17,R25,R35) of four residents reviewed for falls in a sample list of 32 residents. Findings include: 1. R8's progress note dated 04/24/2025 at 6:46AM documents (R8) called and when CNA answer call light found him on floor bedside bed with blood on tray table and floor from apparent nose bleed. ROM within normal limited. Orient to person, time and situation but did not know where he was. Pupils equal but no reaction to light. Assisted up by three people, gait belt and walker. After getting him to bed wanted to know why cowboys went outside the window. (R8) had abrasions on nose, chin and right knee and skin tears to both hands. Areas cleaned and steri strips applied to both hands. TPR (Temperature, Pulse, Respirations) 98.9,80,18 and BP (Blood Pressure) 149/66. Accucheck (blood glucose) 233. Sent to ER (Emergency Room) per 911. Phone with (R8). The facility…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Ecited before2025-06-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. R8's current physician's orders printed 6/10/25 include a physician's orders for an indwelling urinary catheter. R8's hospital admission paperwork dated 4/29/25 to 4/30/25 documents R8 was diagnosed and treated for a Urinary Tract Infection. On 6/8/25 at 2:00PM R8 was observed to have a urinary catheter attached to a drainage bag hanging on the side of his bed. There was no sign on the door to indicate Enhanced Barrier Precautions (EBP) were in place and no bin of Personal Protective Equipment observed outside R8's door. On 6/9/25 at 3:07 PM V2, Director of Nursing verified that since R8 has an indwelling urinary catheter he should be on EBP and further verified R8 is not on EBP. Based on observation, interview and record review the facility failed to initiate/maintain Enhanced Barrier Precautions (EBP) for four (R26, R241, R36, R8) of four residents reviewed for EBP on a sample list of 32 residents. Findings include: The Policy dated 4/1/2024 for Enhanced Barrier Precautions for Skilled Care states that…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to respect the dignity of one resident of 12 residents (R5) reviewed for dignity in a sample list of 32. Findings Include: R5's current diagnoses list printed 6/10/25 includes the following diagnoses: Parkinson's Disease, Cognitive Communication Deficit, Difficulty in Walking, Muscle Weakness, Lack of Coordination, Dysphagia, Psychotic Disorder, Anxiety, and Major Depression. On 6/8/25 at 8:45AM R14, (R5's roommate/spouse) stated The staff always leave my wife in the dining room until last. She is in the dining room now with her breakfast all over her wheelchair. Sometimes they really rush (R5). She has Parkinson's and it upsets me to see this. (R5) gets anxious and will fight them (the staff). R5 was observed to be in the dining room with only one other resident. R5's head was tipped forward and R5 appeared to be asleep. R5 had food on her pants, face and the sides of her wheelchair. There was visible dried debris in R5's wheelchair seat. On 6/10/25 at 10:15AM V17, CNA (Certified Nurse's Aide) stated, I work…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the resident's right to be free from misappropriation of property for one of one resident (R14) reviewed for misappropriation in a sample of 32 residents. Findings include: R14's Minimum Data Set (MDS) dated [DATE] documents R14 is cognitively intact. On 6/8/25 at 8:45AM R14 stated In February my lock box with my wallet and cards went missing from my room. I had the key but I went to the box to get my wallet out and the whole box was gone. They tried to say maybe my wife (roommate) misplaced it but they searched the whole room and it was never found. My kids canceled my cards and got me a new one. Now they keep the box locked in the medication room and I sign out my wallet when I take it and return it. I often go out to breakfast with my friends so I keep $100.00 or less to do that. I don't like to have to mess with ATM (Automated Teller Machines) machines so my son-in-law brings me cash and I keep only a debit card now. When asked if he had any…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-10 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to complete a baseline assessment or identify and track targeted behaviors, prior to restarting an antipsychotic medication for one resident (R14) of five residents reviewed for unnecessary medication in a sample list of 32 residents. Finding Include: R14's current physician's orders include an order dated 4/16/25 for Olanzapine (antipsychotic) Oral Tablet 2.5 MG (milligrams), Give 1 tablet by mouth one time a day. R14's Medication Administration Record (MAR) documents this medication had previously been discontinued on 3/19/25. There is no documentation to indicate a baseline assessment was completed when restarting this antipsychotic medication. There is no documentation of identification or tracking of target behaviors for the justification of this medication. On 6/9/25 at 3:07PM V2, Director of Nursing (DON) verified there was no assessment completed or targeted behaviors identified for R14 when the Olanzapine was restarted. The facility's policy for psychotropic medication revised 3/25/25 documents It is the policy 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 observation, interview, and record review the facility failed to ensure a care plan was accurate and updated to reflect current fall interventions for one (R25) of four residents reviewed for falls in the sample list of 32. Findings include: On 6/09/25 at 10:21 AM R25 was asleep and lying in bed with a raised edge mattress. R25's bed was low to the floor and a fall mat was on the floor. R25 did not have a bed alarm. R25's Minimum Data Set, dated [DATE] documents R25 has severe cognitive impairment, is dependent on staff for toileting hygiene, and requires substantial/maximal staff assist for transfers. R25's nursing note dated 4/24/25 at 7:53 AM documents around 3:15 AM R25 was heard yelling for help and was found sitting on the floor next to her bed. This note does not document the use of a bed alarm. R25's Care Plan dated 3/11/24 documents R25 is at high risk for falls and includes a fall intervention for a bed alarm initiated 3/11/23. R25's Kardex Report dated 6/9/25 documents the use of a bed alarm…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to coordinate hospice care to address positioning needs for one (R25) of one resident reviewed for positioning in the sample list of 32. Findings include: On 6/08/25 at 9:07 AM R25 was in the dining room sitting in a reclined geriatric chair. R25 was leaning to the left with her left arm/side resting on the arm rest of her chair. There was a scabbed area on R25's left outer wrist. At 11:54 AM R25 was in the reclined geriatric chair. R25 was leaning to the left and a pillow was positioned underneath her left arm. On 6/8/25 at 12:32 PM the pillow underneath R25's left arm had fallen, and R25 was still leaning to the left on the arm rest of the chair. V6 Certified Nursing Assistant lifted R25's left arm and placed the pillow underneath R25's arm. V6 stated R25 has leaned like that ever since V6 has worked in the facility, which has been about two to three months. R25's Minimum Data Set, dated [DATE] documents R25 has severe cognitive impairment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-10 · tag F0554 — isolated
    Allow 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-10 · tag F0887 — isolated
    Educate 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

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 / managerTypeRoleSince
ARMSTRONG, CARLOSIndividualCORPORATE DIRECTORsince 04/15/2021
BEATY, CHADIndividualCORPORATE DIRECTORsince 06/20/2024
BUETTNER, CHRISIndividualCORPORATE DIRECTORsince 06/18/2019
CURTIS, SARAHIndividualCORPORATE DIRECTORsince 06/15/2017
DEKEERSGIETER, MARKIndividualCORPORATE DIRECTORsince 06/20/2024
FRERICHS, TROYIndividualCORPORATE DIRECTORsince 04/15/2021
HALL, MONICAIndividualCORPORATE DIRECTORsince 05/15/2021
HINCH, NATEIndividualCORPORATE DIRECTORsince 06/16/2022
HOSEA, ARLENEIndividualCORPORATE DIRECTORsince 06/20/2024
MCCLELLAN, STEPHANIEIndividualCORPORATE DIRECTORsince 02/27/2025
SCHILL, KELVINIndividualCORPORATE DIRECTORsince 02/20/2020
TEICHMAN, CARLIndividualCORPORATE DIRECTORsince 08/20/2015
YONT, GREGIndividualCORPORATE DIRECTORsince 08/17/2023
RIEHLE, MATTHEWIndividualCORPORATE OFFICERsince 02/14/2023
WILLIAMS, KATIEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 06/08/2015
BAKER, CHRISTINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/10/2019
LAU, DANIELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 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.

$17.5M
Net patient revenuemost recent cost report
-81.5%
Operating marginrevenue minus expenses

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

$540per resident / day
operating cost
$16,412per month
≈ monthly operating cost
$297per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 2026-09-01 — CMS provider number 145400. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-29, 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.

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