Loft Rehab & Nursing Of Canton
2081 North Main Street, Canton, IL 61520 · For profit - Corporation · 90 certified beds · (309) 647-6135 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has 3 actual-harm citations
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $134,115 in federal fines (most recent 2026-03-17)
- its payroll-based staffing rating is low (1/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.2% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 38.2% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.5% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 30.4% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 18.3% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.3% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.5% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 2.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 94.7% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.0% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.9% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.97 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.11 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
50.1% 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 80 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 72.7% 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 22 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 36% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 50.1%CMS range 39.2–59.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.2%CMS range 7.8–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 72.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 50.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.0%CMS range 4.7–14.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 63.7 residents a day — about 71% occupied, or roughly 26 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 2.92 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 2.67 hrs/resident/day on weekends vs 3.02 on weekdays — 12% thinner on weekends. RN hours go from 0.76 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 13 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2026-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent a burn injury caused by a homemade hot pack application for one (R1) of 14 residents reviewed for incidents and accidents. This failure resulted in R1 sustaining a blister thermal burn to R1's left outer knee requiring medical treatment. Findings include: R1's medical record documents in part that R1 was admitted to the facility on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease); Mild Protein-Calorie Malnutrition; Type 2 Diabetes Mellitus; Hereditary and Idiopathic Neuropathy, and on 2/16/26 additional diagnoses of Multiple Fracture of Ribs, Bilateral Sequela and Acute Respiratory Failure. R1's medical record documents R1 has mild cognitive issues with a BIMS/Brief Interview for Mental Status score of 11 of 15. R1's medical record documents R1 had bilateral knee discomfort and complained of pain to his left knee area following a fall on 12/08/25. A Nursing Progress Note by V3 (Wound…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-08-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's anticoagulant therapy was maintained related to a diagnosis of Atrial Fibrillation, obtain a valid physician order prior to discontinuing the medication, and document clinical justification to discontinue a residents anticoagulant therapy for one of three residents (R1) reviewed for quality of care in a sample of three. These failures resulted in (R1) who was at high risk for thromboembolic (blood clots that form in one location and travel to another location, potentially blocking blood flow) events, experienced complications from a suspected complication of Acute Cerebrovascular Accident due to Cerebrovascular Disease and passed away after Xarelto was discontinued for 75 days without physician authorization or documented clinical justification.Findings include: R1's admission Record, dated [DATE], documents R1 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Chronic Obstructive Pulmonary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-11-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to use extensive assistance of two staff members during a mechanical lift sit-to-stand transfer for one of four residents (R3) reviewed for falls in a sample of eight. This failure resulted in R3 falling during a mechanical lift sit to stand transfer, sustaining a severely painful dislocated left shoulder. Findings include: The facility's Safe Resident Handling/Transfers policy, dated 12/15/22, documents Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable, experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of a mechanical lifts are 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.
- Potential for harm · D2025-08-05 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 notify a resident's representative of a significant change of medication regimen for one of three residents (R1) reviewed for notification of change in a sample of three. Findings include:The facility's Notification of Changes Policy dated 2/10/25, documents Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member of legal representative when there is a change requires such notification. Circumstances requires notification of change include: 3. Circumstances that require a need to alter treatment. This may include b. Discontinuation of current treatment due to i. Adverse consequences. ii. Acute Condition. Iii.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the resident's representative was involved with the interdisciplinary team quarterly to review and revise a resident's care plan for one of three residents (R1) reviewed for care plans in a sample of three. Findings include: R1's Care Plan Sign in Sheet, dated 5/13/25, only documents V4's (Social Service Director) signature as attending R1's care plan meeting held on 5/13/25. R1's IDT (Interdisciplinary) Care Plan Care Conference, dated 5/13/25, documents V4 (Social Service Director), R1, V6 (R1's Spouse), and V7 (R1's Family Member) attended the care conference. This same Care Conference documents (R1) had her care plan today, (V6 R1's Spouse) and her son (identified as V7 R1's Family Member) attended. Due to no other department managers being available for the care plan the family would like it rescheduled for about a month with all department managers. On 8/4/25 at 9:28 AM V5 (R1's Power of Attorney) stated (R1) admitted to the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-05 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure coordination of care and communication between the facility and hospice provider for one of one resident reviewed for hospice services in a sample of three. Findings include:The facility's Agreement with Hospice Care, dated and signed [DATE], documents Coordination of Services: Hospice Provider and Facility have agreed to participate in a system of communication as described in Hospice Provider's policies and procedures to: 1. Ensure the Hospice Provider's IDG (Interdisciplinary Group) maintains responsibility for directing, coordinating, and supervising the care and services provided. 1. Ensure that the care and services are provided in accordance with Hospice Provider Plan of Care. 1. Ensure that the care and services provided are based on assessment of the Hospice Patient and family needs. 1. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-22 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to implement Infection Prevention and Control Practices after residents were subjected to direct contact from a staff member who tested positive for COVID-19 (Coronavirus 2019) and after residents exhibited symptoms of COVID-19. These failures have the potential to affect all 67 residents residing within the facility. Findings include: The facility's Daily Census Report dated 1-21-25 documents 67 residents currently reside within the facility. The facility's COVID-19 (Coronavirus 2019) Prevention, Response, and Reporting policy dated 10-1-24 documents, It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance. Staff will alert to signs of COVID-19 and notify the resident's physician/practitioner if evident fever/chills, cough, shortness of breath/difficulty…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the Facility failed to provide physician ordered treatments for three of three Resident's (R1, R2 and R3) reviewed for wound care in a sample of three. Findings include: Facility Wound Treatment Management Policy, revised 8/19/24, documents: to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; and wound treatments will be provided in accordance with physician orders including the cleansing method, type or dressing and frequency of dressing change. Facility Physician/Practitioner Orders, revised 12/13/23, documents: the attending physician/practitioner may include, but is not limited to wound care. The Facility Administrator Job Description, dated 6/2021, documents the position purpose as leading, guiding and directing the operations of the healthcare facility in accordance with local, state and federal regulations standards and established facility policies and procedures to provide appropriate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and record review, the facility failed to ensure food is prepared under sanitary conditions by not using Personal Protective Equipment (PPE) properly to prevent hair from contacting food. This failure has the potential to affect all residents with a current census of 65 residents. Findings include: The Hair Restraint; Jewelry; Nail Polish; False Eyelashes policy, dated 11/10/21, documents Food and nutrition services employees shall wear hair restraints and beard guards. Hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated. Dietary staff must wear hair restraints to prevent their hair from contacting exposed food. If a hat is worn, a hairnet must be worn under the hat if any hair is exposed from under the hat. On 8/21/24 at 11:15 AM, two maintenance men (vendor) were observed to be in the kitchen working on an ice machine without hair or beard restraints donned. On 8/21/24 at 11:20 AM, V13 (Cook) was observed to have multiple pieces of hair exposed from under the hair restraint while preparing lunch trays. On 8/21/24…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-22 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has 2 deficient practice statements. A. Based on record review, observation and interview, the facility failed to wear Personal Protective Equipment (PPE) appropriately, failed to disinfect patient use items and failed to conduct hand hygiene per policy for one of three residents (R41) reviewed for infection control practices in a sample of forty residents. B. Based on observation, interview and record review the facility failed to pass medications in a manner to prevent contamination. This failure has the potential to affect the 19 residents who reside on the 400 hall (R1,R5,R6,R12,R16,R19,R23,R26,R27,R31,R32,R36,R29,R46,R50,R54,R56,R60 and R61) in a total sample of forty. Findings include: A. The Enhanced Barrier Precautions policy, dated 1/1/24, documents Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. b. An order for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 record review and interview the facility failed to provide a completed transfer document for one resident (R68) of 2 residents reviewed for discharge in a total sample of forty. Findings Include: The Facility's Transfer and Discharge policy dated 1/30/24 documents Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. The Facility's Transfer and Discharge policy dated 1/30/24 documents for Emergency Transfers/Discharges that the nurse will Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: Resident status, including baseline and current mental, behavioral and functional status and recent vital signs; Current diagnosis, allergies and reason for transfer/discharge; Contact information of the practitioner…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
Based on observation, interview and record review the facility failed to perform personal care for one resident (R20) of twenty residents reviewed for clean and well kempt appearance in a total sample of forty. Findings Include: The Facility's Activities of Daily Living Policy dated 12/5/23 documents Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. The policy also documents A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene and oral hygiene. R20's Electronic Medical Record documents that R20 was admitted for Hospice Care due to adult failure to thrive and muscle wasting. R20's Point of Care Response History documents that on 8/17/24 R20 was totally dependent for bathing and grooming. On 8/20/24 at 9:00 AM R20 was lying in bed in a hospital gown with full beard stubble with a longer mustache that covered his entire lips. R20's fingernails were also long. R20 stated I've been asking (staff) to shave…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-08-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete diabetic monitoring and care for one of two residents (R41) reviewed for quality of care in a sample of 40 residents. Findings include: R41's Minimum Data Set (MDS) documents R41 was admitted on [DATE] with Type 2 Diabetes Mellitus with Insulin Dependence. R41's Physician's Standing Orders, undated, documents Diabetes: Unless otherwise indicated: blood glucose monitoring before meals and at bedtime. If no sliding scale ordered, may use the following scale . R41's Hospitalization Discharge summary, dated [DATE], documents Insulin to be administered per sliding scale every four hours. R41's Progress Note document R41 returned to the facility post hospitalization on 8/16/24 at 3:45 PM. R41's Blood Glucose Monitoring log documents a blood glucose level was conducted on the facility's admission assessment on 8/16/24 at 5:30 PM and not again until 8/19/24 at 11:06 AM. R41's Progress Note dated 8/19/24 at 10:09 AM documents Resident had been yelling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2024-08-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure catheter care was conducted for one of nine residents (R41) with indwelling catheters in a sample of forty residents. Findings include: R41's Care plan, dated 7/29/24, documents Indwelling Catheter for wound healing. Monitor/record/report to Medical Doctor for signs and symptoms Urinary Tract Infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R41's Progress Notes, dated 8/3/24 at 9:49 PM, documents Husband concerned that R41 may be getting a Urinary [NAME] Infection. New Catheter bag in place for clean catch (urine sample). Will pass on to next nurse to collect urine if signs and symptoms for urinalysis to be collected. R41's Progress Notes, Physician Orders and Laboratory Results lacks documentation a urinalysis was obtained. R41's Progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to identify specific triggers of re-traumatization for two residents (R1, R6) reviewed for PTSD (Post Traumatic Stress Disorder) of three residents reviewed for Trauma Informed Care in the sample of 40. Findings include: Facility Policy/Trauma Informed Care dated 1/30/24 documents: A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. While most triggers are highly individualized, some triggers may…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-22 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify an appropriate indication for use and identify target behaviors for the use of an antipsychotic medications for three of five residents (R28, R32, R39) reviewed for unnecessary medications in a sample of forty residents. Findings include: Facility Policy/Use of Psychotropic Medication dated 9/27/23 documents Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. Enduring Conditions (i.e., non-acute, chronic, or prolonged):The resident's symptoms and therapeutic goals shall be clearly and specifically identified and documented. An evaluation shall be documented to determine that the resident's expressions or indications of distress are:Not due to a medical condition or problems that can…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the Care Plan to ensure a fall did not occur for one (R1) resident of three residents reviewed for falls/accidents in a sample of three Findings include: The facility's Incidents and Accidents Policy, dated 12/6/22, documents: It is the policy of this facility for staff to utilize (Electronic Health Record)/Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. R1's diagnoses included: Dementia, psychotic disturbance, mood disturbance, chronic kidney disease, malignant neoplasm of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-10-25 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to provide the service of a Registered Nurse (RN) eight hours a day seven days week. This has the potential to affect all 65 residents residing in the facility. Findings include: The facility's Facility Assessment dated 12/2022 documents, At least 10% must be provided by RN. V1, Administrator, verified that out of the 100% direct care staffing hours needed per 24 hours, at least 10% of those hours have to be completed by an RN equaling a minimum of eight hours a day. The facility's daily nurse staffing schedules dated 9/23/23 through 10/25/23, documents the facility did not have an RN scheduled on 9/23, 9/24, 10/1, 10/7, 10/8, and 10/22. On 10/25/23 at 1:17 PM, V1, Administrator, verified there was no RN coverage of the before mentioned dates and stated, We don't have an RN right now to cover all the weekends. We're trying to get some hired. The facility's resident roster report dated 10/24/23 and verified by V1, Administrator, documents 65 residents residing in the facility.
- Potential for harm · Dcited before2023-09-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to immediately assess a newly acquired wound, implement new skin interventions, obtain a treatment order upon wound identification, revise a wound care plan, and follow physician orders for wound care for two of three residents (R2, R3) reviewed for wounds in the sample of five. Findings include: The facilities Wound Treatment Manage policy dated, 8/22/2023, documents, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders, or the assigned licensed nurse in the absence of the treatment nurse. This same policy also documents Treatments will be documented 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.
- Potential for harm · D2022-08-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop a care plan for a high fall risk resident for one (R42) of 26 residents reviewed for care plans in the sample of 26. Findings include: The facility's Incidents, Accidents, and Supervision policy and procedure, dated 01/01/2020, documents, The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents . The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. This policy documents Identification of Hazards and Risks, Evaluation and Analysis, Implementation of Interventions, Monitoring and Modification, and Supervision are means the facility will use to develop a plan of care for each resident. On 8/16/22 at 11:02 AM, R42 was lying in a low bed with a bandage to the right lateral eye area, that was partially off on one corner. During this same time V17 (R42's) Family Member was at R42's bedside and stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to revise current resident care plans for two (R30 and R31) of 26 residents reviewed for Care Planning in the sample of 26. Findings include: The facility's Comprehensive Care Plan policy, documents The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 1. R30's current Care Plan documents R30 has potential for pressure ulcer development related to needing assistance with bed mobility, Type 2 Diabetes, and incontinence. On 8/16/22 at 10:40 AM R30 was lying in bed on her back with her eyes closed. On 8/16/22 at 11:18 AM R30 was sitting upright in bed slightly leaning to the left with her eyes closed. On 8/16/22 at 11:55 AM, R30 remained sitting in bed unchanged from 11:18 AM. On 8/16/22 at 1:10 PM R30 was lying in bed on her back with her eyes closed. On 8/17/22 at 8:40 AM, R30 was lying in bed on her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a physician ordered wound dressing was in place and ensure cross contamination did not occur during a wound treatment for one (R31) and failed to turn and reposition one (R30) of two residents reviewed for positioning and wound care in the sample of 26. Findings include: The facility's Wound Treatment Management Policy (Dated 8/1/19) documents: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Dressing changes may be provided outside the frequency parameters in certain situations: The dressing has dislodged; The dressing is soiled otherwise or is wet. The facility Standard Precautions Infection control policy and procedure, revised 01/01/29, documents All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure infection control practices were maintained to prevent cross contamination during pressure ulcer wound care and ensure physician ordered wound dressing was in place for one (R30) of four residents reviewed for pressure ulcers; and failed to follow its policy and physician orders for wound treatment for one (R35) of four residents reviewed for wound treatments in the sample of 26. Findings include: The facility's Wound Treatment Management Policy (Dated 8/1/19) documents: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Dressing changes may be provided outside the frequency parameters in certain situations: The dressing has dislodged; The dressing is soiled otherwise or is wet. The facility Standard Precautions Infection control policy and procedure, revised 01/01/29, documents All staff are to assume that all residents are potentially infected or colonized with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to investigate a fall and conduct a root cause analysis and failed to implement new interventions or increase supervision for one (R42) of two residents reviewed for falls in the sample of 26. Findings include: The facility's Incidents, Accidents, and Supervision policy and procedure, dated 01/01/2020, documents The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary . 1. Identification of Hazards and Risks . 1. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. 2. Evaluation and Analysis . c. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure there was a clinical indication for use of an indwelling urinary catheter for one (R34) and failed to ensure infection control procedures were performed during indwelling urinary catheter cares for one (R30) of three residents reviewed for indwelling urinary catheters in the sample of 26. Findings include: The facility Catheter Care policy and procedure, dated 12/2/2021, documents It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. This policy documents to Perform hand hygiene and Don (apply) gloves. Female: 9. Gently separate the labia to expose the urinary meatus. 10. Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). 11. Use a new part of the cloth or different cloth for each side. 12. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-19 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
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 follow its policy and physician orders for PICC (Peripherally Inserted Central Catheter) line dressing change treatments for one (R35) resident reviewed for PICC lines in the sample of 26. Findings include: The facility's PICC (Peripherally Inserted Central Catheter) Dressing Change Policy (Dated 1/1/20) documents: It is the policy of this facility to change peripherally inserted central catheter (PICC) dressing, weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. The facility's documentation from local hospital, dated 2/4/22, documents: (R35) had developed bilateral deep decubitus ulcerations on her bilateral ischial tuberosities as a result of a fall and sitting in her bathtub for three days in late December. She developed fevers, chills, and weakness. She was admitted to the hospital for concern of osteomyelitis versus deep wound infection. Impression: Bilateral ischial tuberosity decubitus ulcers with osteomyelitis. We are going to place a PICC line today (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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$134,115 in federal fines across 3 penalties. 1 Medicare payment denial on record.
- $27,265 — penalty dated 2026-03-17
- $85,860 — penalty dated 2025-11-22
- $20,990 — penalty dated 2025-08-05
- Medicare payment denial — starting 2025-12-16 for 2 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to THE LOFT REHABILITATION AND NURSING — 7 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 1.9 | +1.1 vs chain |
| Staffing | 1 of 5 | 1.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 3.6 | -0.6 vs chain |
The other 6 homes this chain runs (chain average 1.9★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| AARON, ADAM | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 23% | since 12/01/2018 |
| AARON, DANIEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 23% | since 12/01/2018 |
| AARON, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 23% | since 12/01/2018 |
| AARON, ROBERT | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 23% | since 12/01/2018 |
| HOWD, JEFF | Individual | W-2 MANAGING EMPLOYEE | — | since 12/01/2018 |
| AARON, FRED | Individual | CORPORATE OFFICER | — | since 12/01/2018 |
CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $334K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145600. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-22, 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 →
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