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Neighbors Health Center

811 West 2nd, Byron, IL 61010 · For profit - Limited Liability company · 131 certified beds · (815) 234-2511 Medicare & Medicaid certified

Call the home — (815) 234-2511 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 20251 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing 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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
UW HEALTH13.8 mi
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
109 N Franklin St · (815) 234-3900 · Call to confirm hours
Pharmacy
415 W Blackhawk Dr · (815) 234-5466 · Call to confirm hours
Grocery
415 W Blackhawk Dr · (815) 234-5100 · Call to confirm hours
Park
500 N Colfax St · (815) 234-8435 · Typically dawn to dusk
Place of worship

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 5 of 5
Long-stay residentspeople who live here 5 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 improved from 4 to 5 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 rating5★
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 increased8.0%13.4%15.4%better
Long-stay residents who lose too much weight6.6%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.9%0.9%better
Long-stay residents with a urinary tract infection1.4%1.5%2.0%better
Long-stay residents with depressive symptoms12.4%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 injury2.8%3.1%3.3%better
Long-stay residents whose ability to walk worsened11.5%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.3%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers4.3%4.8%4.7%typical
Long-stay residents with worsening bladder/bowel control19.9%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table21.0%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.4%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine89.1%63.1%79.4%better
Short-stay residents rehospitalized after admission22.5%26.1%22.6%typical
Short-stay residents with an outpatient ER visit3.3%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.222.021.67better
Long-stay outpatient ER visits per 1,000 resident days0.312.221.80better

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.

56.9% 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 146 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.9%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
48.6%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 48.6% 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 74 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.9%CMS range 47.0–65.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.6–14.410.7%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 discharge48.6%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 discharge54.0%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 discharge21.6%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 identified100.0%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 worsened4.0%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 hospitalization5.9%CMS range 3.0–8.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.091.02Oct 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

0.49
RN hours/ resident / day
0.76
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
0.28
RN hoursweekends
43.3%
Total nursing turnover
42.9%
RN turnover

How full it usually is: this home is certified for 131 beds and averages 99.3 residents a day — about 76% occupied, or roughly 32 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.84 hrs/resident/day on weekends vs 3.53 on weekdays — 19% thinner on weekends. RN hours go from 0.58 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% 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

4
deficiencies at the latest standard inspection (2026-05-07)
5
at the previous standard inspection (2024-09-05)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2025-05-20 · 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 keep a resident free from physical abuse. This applies to 4 of 6 residents (R1, R2, R3 & R4) reviewed for abuse in the sample of 41. This failure resulted in R1 being sent to the local hospital and diagnosed with a posterior head laceration and initial CTH with acute SDH (computed tomography with acute subdural hematoma) of the left frontal, parietal, and temporal lobes. The findings include: 1. The facility's final report to the state surveying agency regional office dated December 20, 2023, shows, It was immediately reported to Administrator (V1) that R1 sustained a fall with injury while in the memory care dining room. Staff reported that they heard a female resident say that a resident is moving the chair around and to leave it alone, when the one CNA (Certified Nursing Assistant) turned toward the resident she saw R1 and another male resident (R2) both had hold of the chair and due to the momentum of both residents tugging at the chair they both…

    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 before2026-05-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure resident dignity was maintained during personal care for 1 of 2 residents (R53) reviewed for dignity in the sample of 43. The findings include:R53's face sheet printed on 5/7/26 showed diagnoses including but not limited to rheumatoid arthritis, dementia, generalized anxiety disorder, and senile degeneration of brain. R53's facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance required for toilet hygiene, dressing, and transfers. The same assessment showed that R53 is always incontinent of urine and bowel. On 5/5/26 at 9:26 AM, V10 and V11 (Certified Nursing Assistants/CNA) transferred R53 from the wheelchair onto the bed using a mechanical lift. R53's bed was next to the room window. The window looked out to the front parking lot and sidewalk. V10 and V11 removed R53's pants and incontinence brief. Peri care was performed and a fresh brief was put on the resident. R53 was naked from 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a urinary drainage bag was off the floor, failed to use a dignity cover, and failed to use personal protective equipment (PPE) during direct catheter care for 1 of 3 residents (R22) reviewed for catheters in the sample of 43. The findings include:R22's face sheet printed on 5/7/26 showed diagnoses including but not limited to right side paralysis following cerebral infarction, heart disease, diabetes mellitus, benign prostatic hyperplasia with urinary tract symptoms, retention of urine, and obstructive/reflux uropathy. R22's facility assessment dated [DATE] showed moderate cognitive impairment and staff assistance required for transfers and personal hygiene. The same assessment showed R22 is always incontinent of bowel. R22's May 2026 order summary report showed an order start dated 11/21/24 for a urinary catheter for urinary retention/obstructive and reflux uropathy. The same report showed an order start dated 4/30/25 for enhanced…

    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 · D2026-05-07 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to follow their policy for food brought in by family or visitors for 1 of 1 resident (R80) reviewed for food safety in the sample of 43. The findings include: On 5/5/26 at 10:05 AM, R80 was seated in a wheelchair in her room. A counter size mini refrigerator was on a stand, next to her bed. The door had a handwritten sign on the front dated 4/1 and it stated do not take anything out of it or throw anything away. The family makes the food for the resident to eat. R80 gave permission for this surveyor to look inside the refrigerator. The small, freezer section was thawed and dripping water over all the items. A plastic storage container with an unidentified liquid was wet and a small baggie of meat was wet. R80 identified the items as soup and lunch meat. There was a baggie of cinnamon bread and a baggie of croissants which were both wet. None of the foods had any dates or labels on them. There was a baggie of grapes and a bottle of syrup on 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to have enhanced barrier precautions in place for residents with pressure wounds. This applies to three of three residents (R2, R47, R105) reviewed for infection control in the sample of 43.The findings include: 1 On 5/6/26 at 10:50 AM R47 was receiving wound care for her stage 3 pressure injury from V8 (Wound Nurse), V9 (Wound Physician) and V16 (Wound Physician's Assistant). No sign was displayed on R47's door showing she was on enhanced barrier precautions and there was no PPE (personal protective equipment) available near her room. V8, V9 and V16 were not wearing a gown during the treatment. On 5/7/26 at 9:08 AM, V8 said R47 did not need to be on enhanced barrier precautions because her dressing was a band-aid like dressing. V8 said when a new wound is found in the facility, the infection preventionist is notified and she determines if they need isolation or not. On 5/7/26 at 9:33 AM, V2 (Infection Preventionist and Assistant Director 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 · D2026-04-09 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to assess a resident for return from an acute care hospitalization and failed to document specific resident needs that cannot be met by the facility upon a resident's proposed return from an acute care stay for 1 of 1 resident (R1) reviewed for involuntary discharge in the sample of 3. The findings include:R1's Nursing Notes on 3/31/26 show that around 5:00 PM, R1 was found in her room cutting her arm with a pair of cuticle scissors. R1 was sent to the hospital. On 4/8/26 at 12:49 PM, V1 (Administrator) said that she filled out an Involuntary Discharge (IVD) Form for R1 on 3/31/26 and it was delivered to the emergency room on 3/31/26. V1 said that it was provided because of the self-harm and she knew that she would require additional support services that the facility was unable to provide to her. V1 said that they haves a psychiatric Nurse Practitioner that comes to the facility every two weeks. V1 said that she received a call from the hospital on 4/2/26 that R1 was ready to be discharged back to the facility. V1 said 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a comfortable temperature range of 71 degrees Fahrenheit to 81 degrees Fahrenheit was maintained for 10 of 11 residents (R1, R3-R11) reviewed for a comfortable environment in the sample of 11.The findings include:On March 23, 2026, there were multiple rooms on the 100 hall of the facility that had multiple blankets on the windowsills of residents' rooms and a blanket over the air conditioning units in the residents' rooms.On March 23, 2026, at 8:55 AM, R1 said her room has been cold. R1 said about a month ago, there were portable heaters in the hallways. R1 said she must have three blankets on her bed to stay warm. R1 said it gets colder at night, and it makes her sad that it cannot be warmer. R1's Minimum Data Set (MDS) dated [DATE], shows she is cognitively intact. R1 has no behaviors of rejecting any care.On March 23, 2026, at 9:08 AM, R5 said it has been cold in the facility for a while. R5 said she has to wear a bunch of blankets when it…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to provide water to residents in a sanitary manner. This applies to 5 of 8 (R1, R2, R3, R4, R5) in the sample of 11 reviewed for dietary services. The findings include: On 6/30/2025 at 11:43AM, observations of residents being given ice water by V6 (Activity Aide). V6 used a scoop that was sitting on the water cart holding the cooler with water and ice. V6 opened the lid of the cooler to fill R5's and R2's cup with the scoop, placed the wet scoop back down on the cart, and took the cup back into the resident's room. V6 was observed holding R3, R4, and R1's water cup that was removed from the resident's room above the open water and ice cooler while filling the cup. On 6/30/2025 at 12:06AM, V7 (Food Service Director) said the scoop should not be placed back on the cart due to risk cross contamination. V7 said the resident's water cup shouldn't be held above the water cooler because of the risk of cross contamination. The facility provided Ice Dispensing policy revised 5/20/2014 states, the healthcare community…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was assessed for a change of condition of 1 of 3 residents (R3) reviewed for change of condition in the sample of 6. The findings include: R3's face sheet documents she was admitted to the facility on [DATE] with a primary diagnosis of pressure ulcer of sacral region, stage 4. She also had diagnosis of unspecified dementia, unspecified severity. The 10/6/24 quarterly resident assessment and care screening shows R3 to have severe cognitive impairment and required supervision/touch assistance for sit to stand and toilet transfers. The same assessment documents her to be occasionally incontinent of urine and frequently incontinent of bowel. On 5/23/25 at 1:40 PM, V10 (Certified Nursing Assistant/CNA) said R3, for the most part, she was confused, and she needed stand by assist. She was always trying to get up out of bed on her own, and she had alarms so we could know when she was moving. V10 said remembers, R3 she was just laying down. We…

    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 · E2025-05-20 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    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 mechanical lift equipment was in good working order for 5 of 5 residents (R8, R19, R36, R40, R41) reviewed for mechanical lifts in the sample of 41. The findings include: On [DATE] at 9:55 AM, V22 (Certified Nursing Assistant/CNA) said on [DATE] she was toileting R36 using the sit to stand machine. V22 said she had R36 standing up with her arms above her head attached to the machine with the sling when she attempted to lower R36 to the toilet. V22 said the battery died and the machine wouldn't lower R36. V22 said she got other batteries and none of the batteries she tried were working. V22 said R36 was getting weak and starting to panic, so she tried to use the emergency release on the machine, and it wouldn't release. V22 said she had to put her knees under R36's bottom, and with a gait belt around R36's waist, manually lower R36 to the wheelchair. V22 showed this surveyor a mechanical lift in the resident hallway and pointed out…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-20 · 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 interview and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 1 of 41 residents (R33) reviewed for dignity in the sample of 41. The findings include: On May 19, 2025, at 1:10 PM, V14 (Licensed Practical Nurse/LPN) stated, her, V9 (LPN) and V12 (Dietary Manager) got into a verbal altercation at the nurses' station. V9 and her work the night shift. They were giving report to the oncoming day shift when V12 (Dietary Manager) overheard them talking about their concerns with the dinner meal the night before. He was calling us wussies and telling us that the menu is planned out by a dietitian. V14 admitted to calling the dietitian a dumb b. Another staff member (V22 Certified Nursing Assistant/CNA) saw what was happening and told her to stop and leave it alone. She admitted to saying 2 cuss words. R33 was up and sitting by the nurses' station. On May 19, 2025, at 1:43 PM, V22 (CNA) stated, V12 (Dietary Manager), V9 (LPN) and V14 (LPN) were arguing at shift change. V12 was punching in the time clock (which is right by…

    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
Show the remaining 14 citations
  • Potential for harm · D2025-05-20 · 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

    Based on interview and record review the failed to ensure an allegation of abuse was reported to the state surveying agency in a timely manner. This applies to 2 of 6 residents (R3 & R4) reviewed for abuse in sample of 41. The findings include: On May 15, 2025, at 8:33 AM, V9 (Licensed Practical Nurse/LPN) stated, R3 & R4 got into a fight in their room, December 2023. R3's progress notes dated December 7, 2023, shows, Resident had a disagreement with his roommate that had escalated between them. Decision was made to separate the roommates per both of their requests. On May 19, 2025, at 12:01 PM, R4 stated, he remembered R3. R3 was threatening to kick his a. He told him, No you won't. R3 came at him, and he knocked him down and started kicking him. I warned him. The facility did not report the incident to state surveying agency or local police department at the time of the incident. R3's progress notes written by V7 (Nurse Practitioner/NP) dated December 12, 2023, shows, CC (current concern): bruising, recent fall. HPI (history of presenting illness): Patient is reporting that 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-20 · 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

    Based on interview and record review the facility failed to assess and treat a resident after the resident hit their head when their wheelchair flipped backwards. This applies to 1 of 3 residents (R34) reviewed for quality of care in the sample of 41. The findings include: On May 20, 2025, at 11:17 AM, V34 (R34's daughter) stated, R34 had appointment at his orthopedic office. The facility transported R34 to the appointment and she met him there. She noticed a scrape on the crown of his head. R34 told her that the guy flipped him over on the way to the appointment. He stopped too fast and flipped him backwards and his head got scraped. She called the facility and asked what was going on. They said they got over booked and the maintenance man (V19) had to drive him to the appointment. The facility was going to have a nurse that previously worked in the neurology department at the hospital look at him. They checked him out and he was fine just had a scrape on the top of his head that was all she knew. On May 20, 2025, at 11:57 AM, R34 stated, he remembers the guy flipping him backwards…

    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 before2025-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were transferred in safe manner with properly working equipment for 3 of 41 residents (R8, R36, R40) reviewed for safety in the sample of 41. The findings include: 1. On [DATE] at 9:55 AM, V22 (Certified Nursing Assistant/CNA) said on [DATE] she was toileting R36 using the sit to stand machine. V22 said she had R36 standing up with her arms above her head attached to the machine with the sling when she attempted to lower R36 to the toilet. V22 said the battery died and the machine wouldn't lower R36. V22 said she got other batteries and none of the batteries she tried were working. V22 said R36 was getting weak and starting to panic, so she tried to use the emergency release on the machine, and it wouldn't release. V22 said she had to put her knees under R36's bottom, and with a gait belt around R36's waist, manually lower R36 to the wheelchair. V22 showed this surveyor a mechanical lift in the resident hallway and pointed…

    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 · D2025-05-20 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents records were up to date and accurate. This applies to 3 of 12 residents (R34, R35 & R36) reviewed for resident records in the sample of 41. The findings include: 1. On [DATE] at 11:17 AM, V34 (R34's daughter) stated, R34 was on his way to an appointment in the transport van and flipped backwards in his wheelchair and hit his head. On [DATE] at 11:33 AM, V19 (Former Maintenance Director) stated, R34 did flip backwards in the transport van on the way to an appointment. On [DATE] at 11:57 AM, R34 stated, he remembered the guy flipping him backwards in the van on the way to his appointment. R34's electronic medical record (EMR) does not show any documentation nor provide any documentation regarding R34's incident in the transport van. On [DATE] at 12:57 PM, V1 (Administrator) stated, the nurses should be documenting any incidents with a progress note and all assessments should be in medical record. The facility's fall…

    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 · E2024-09-05 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
    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 interview and record review, the facility failed to ensure accurate weights were obtained and recorded for 5 of 5 residents (R13, R47, R86, R95, R98) reviewed for nutrition in the sample of 20. The findings include: 1) R98's electronic face sheet printed on 9/5/24 showed R98 has diagnoses including but not limited to necrotizing fasciitis, cerebral infarction, diarrhea, cutaneous abscess of groin, and chronic pain. R98's weight log showed, 7/27/24 197.4lbs 7/28/24 175.6lbs (21.8lb weight loss in 1 day). 8/2/24 195.4lbs 8/3/24 188.4lbs (7lb weight loss in 1 day). 8/6/24 192.8lbs 8/8/24 182.8lbs (10lb weight loss in 2 days). R98's nursing progress notes for July-August 2024 showed no documentation that R98 was reweighed or that a physician was notified of any significant weight loss. On 9/5/24 at 10:46AM, V2 (Director of Nursing/DON) stated, When a significant weight change is identified, staff should get a reweigh on the resident to ensure the weight is accurate. As a nurse, I would say the standard 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to securely store medications. This applies to 1 of 6 medication carts reviewed for medication storage. The findings include: On 9/5/24 at 10:45 AM, V3 (Assistant Director of Nursing) was assisting this surveyor during medication storage review. V3 said she had to find the nurse on the hall to get the keys to the cart and walked away from the surveyor. When V3 returned to the medication cart she opened the narcotic count binder that was laying on the right side of the cart and the nurse's keys were laying just under the binder cover. V3 removed the keys from the binder and proceeded to open the medication cart. On 9/5/24 at 10:50 AM, V3 said the keys to the medication cart and medication rooms should be on the nurse and not laying on the medication cart. V3 said she did not know why the nurse would have left the keys on the cart. On 9/05/24 at 11:33 AM, V2 (Director of Nursing) said the keys to the medication cart should be with the nurse at all times. V2 said it is important to keep the medications secure and to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-09-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform glove changes and hand hygiene during incontinence care for 1 resident (R61). The facility also failed to transport linens in a manner to prevent cross contamination on 1 of 5 units. These failures apply to 14 of 14 residents reviewed for infection control in the sample of 20. The findings include: 1. The facility roster dated [DATE] showed 13 residents residing on the unit where V5 (Certified Nursing Assistant/CNA) was working on [DATE]. On [DATE] at 8:50AM, V5 provided incontinence care to R63. R63's bed pad was saturated with urine when V5 picked up R63's soiled linen, held it against her body, and transported it down the hallway to the soiled linen container. V5 did not bag R63's soiled linen. V5 returned to R63's room, completed her cares, then left R63's room and went to the dining room to assist with the remainder of the breakfast meal. V5 did not change her clothing and stated she knows she should have put the soiled…

    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 · D2024-09-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) assistance to 2 of 3 residents (R63,R86) reviewed for activities of daily living in the sample of 20. The findings include: 1) R63's electronic face sheet printed on 9/5/24 showed R63 has diagnoses including but not limited to Alzheimer's disease, major depressive disorder, dementia with psychotic disturbance, and type 2 diabetes. R63's facility assessment dated [DATE] showed R63 has moderate cognitive impairment. R63's Restorative assessment dated [DATE] showed R63 requires maximum assistance for oral hygiene and personal hygiene. R63's care plan dated 3/9/23 showed, (R63) is at risk for ADL decline related to muscle weakness, dementia, and anxiety .dependent on staff for personal hygiene. On 9/4/24 at 8:50AM, V5 (Certified Nursing Assistant/CNA) provided morning care for R63. V5 provided incontinence care, dressing assistance, and brushed R63's hair. V5 did not provide or offer to brush R63's…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an indwelling urinary drainage bag remained below the bladder level for 1 of 2 residents (R61) reviewed for catheters in the sample of 20. The findings include: R61's undated face sheet showed diagnoses including but not limited to cerebral infarction, heart disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and urinary tract infection. R61's facility assessment dated [DATE] showed moderate cognitive impairment and the use of a urinary catheter. The same assessment showed total staff assistance required for transfers. R61's September 2024 physician order report showed the use of an indwelling catheter for urinary retention start dated 8/8/24. R61's August 2024 medication administration history report showed the use of cephalexin and levofloxacin (antibiotics) were given to treat a urinary tract infection (UTI). On 9/3/24 at 9:53 AM, R61 was lying in bed and was alert. R61's catheter bag was in the bed laying 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 · D2023-10-18 · 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

    Based on observation, interview, and record review the facility failed to re-evaluate a resident's ability to safely self-administer medications for 1 of 1 resident (R46) reviewed for self-administering of medications in the sample of 20. The findings include: On 10/16/23 at 08:56 AM, on R46's bedside table was a plastic medication cup that contained 4 pills. R46 said staff leave the pills for her to take when her meal tray is delivered to her room. On 10/16/23 at 11:23 AM, V3 (Licensed Practical Nurse- LPN) said R46's medications are left at her bedside to be self-administered. R46's Resident Progress Notes dated 10/16/23 showed, Resident self-administers medications on a daily basis. R46's Physician Order Report showed an order for medications to be left at R46's bedside to be self-administered. The order history report showed the order was entered on 10/16/23 at 11:29 AM. R46's Care Conference Note dated 5/30/23 showed it was determined R46 was safe to self-administered medication. The facility's Self Administration of Drugs policy with a reviewed date of 5/22 showed, Quarterly…

    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 before2023-10-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a fall prevention intervention was in place and failed to safely transfer a resident by not using a gait belt for 2 of 20 residents (R92 and R3) reviewed for safety in the sample of 20. The findings include: 1. R92's Care Plan indicated R92 was at risk for falls due to confusion, general weakness, and a history of repeated falls. Listed under approach was, Equip resident with a device that monitors rising. On 10/16/23 at 01:35 PM, R92 was in his room sitting in his reclining chair sleeping. There were no staff present in the room or visible in the hallway. There was a gray cord coming out of the seat portion of the reclining chair. The cord was resting on the floor and was not plugged into anything. On 10/16/23 at 02:22 PM, V5 (Certified Nursing Assistant/CNA) confirmed the cord was unplugged and the cord was for R92's chair/position alarm. V5 said the cord needed to be plugged into the alarm box for the chair/position alarm to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide incontinence care for dependent residents in a manner to prevent cross contamination for 2 of 20 residents (R43 and R58) reviewed for infection control in the sample of 20. The findings include: 1. R43's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include hypertensive, heart and chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, retention of urine, and diastolic heart failure. R43's facility assessment dated [DATE] showed she requires extensive assistance of one staff member for toileting needs and is always incontinent of urine and frequently incontinent of bowel. R43's care plan initiated 7/26/23 and revised 10/5/23 showed, [R43] is on contact isolation related to MDRO (multidrug resistant organism) . Use appropriate PPE (personal protective equipment) when providing care . R43's 7/28/23 Nurse Practitioner note showed, HPI (History of Present…

    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 · D2023-09-18 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's representative was notified of a resident's increase in behaviors, a new skin tear, and bruising for 1 of 3 residents (R1) reviewed for notification in the sample of 9. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Urinary Tract Infection, hypothyroidism, hypertension, major depressive disorder, and asthma. R1's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires assistance from staff for all cares. On 9/17/23 at 9:31 AM, V11 (R1's Power of Attorney) said the biggest problem that she has with the facility is that they don't notify her when R1 is having behaviors. V11 said R1 had an episode that resulted in a skin tear and bruises. V11 said she had come into the facility for a visit on Sunday (7/23/23) and noticed R1 had a bandage on her arm and bruises. V11 said she asked the CNAs on duty…

    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 before2023-09-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide incontinence care in a manner to prevent cross contamination for 2 of 4 residents (R2, R4) reviewed for incontinence care in the sample of 9. The findings include: 1. R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include hypertensive heart disease, chronic kidney disease, vascular dementia, major depressive disorder, paroxysmal atrial fibrillation, and osteoarthritis. R2's facility assessment dated [DATE] showed she has severe cognitive impairment and requires extensive assistance of staff for all cares. R2's care plan initiated 4/22/23 showed, . Toilet Use: [R2] is incontinent of her B&B (bowel and bladder). Extensive assist for toileting, peri care, and dependent for changing her lower body clothing . On 9/17/23 at 12:58 PM, R2 was being assisted to use the bathroom by V4 and V5 (Certified Nurse Assistants/CNAs). V4 and V5 wheeled R2 into the restroom and donned gloves. V4 and V5 performed a…

    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.

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

No federal fines in the current CMS record.

Part of a chain

This home belongs to GENERATIONS HEALTHCARE NETWORK — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 52.5+2.5 vs chain
Health inspection 4 of 52.5+1.5 vs chain
Staffing 2 of 52.0≈ chain avg
Quality measures 5 of 53.0+2.0 vs chain
The other 3 homes this chain runs (chain average 2.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
BARRISH GROUP LIMITED PARTNERSHIPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 06/01/2008
RALPH GESUALDO CHILDRENS TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 06/01/2008
BARRISH, BRYANIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST13%since 06/01/2008
GESUALDO, RALPHIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR13%since 06/01/2008
GIANNINI, MICHAELIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR11%since 06/01/2008
HOPPE, JENNIFERIndividualW-2 MANAGING EMPLOYEEsince 04/16/2018
WINTER, THOMASIndividualCORPORATE DIRECTORsince 06/01/2008
BERGTHOLD, LOUISEIndividualCORPORATE OFFICERsince 11/01/2013

CMS files one row per role, so the 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$11.2M
Net patient revenuemost recent cost report
-3.0%
Operating marginrevenue minus expenses
$1.9M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 13%Medicare 10%Other / private 77%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

$314per resident / day
operating cost
$9,545per month
≈ monthly operating cost
$305per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

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 2026-08-01 — CMS provider number 145440. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, 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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