Carlinville Rehab & Hcc

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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.

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.

38.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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.

Staffing

How full it usually is: this home is certified for 98 beds and averages 74.5 residents a day — about 76% occupied, or roughly 24 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 2.66 hrs/resident/day on weekends vs 3.33 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.49 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

38 citations, most serious first. The 16 most serious are shown; the remaining 22 are one tap away and print in full.

• Actual harm · Gcited before2025-12-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer an ordered intravenous, IV, antibiotic, timely transport, and contact prescribing Physician for 1(R2) of 3 residents in the sample of 23. This failure resulted in R2's course of treatment being interrupted, R2 needing to have six additional days of IV antibiotics, and the potential of septic infection. Findings include:R2's undated face sheet documents an admission date of 11/28/2025 and a discharge date of 12/4/2025. Diagnosis include Fournier Gangrene, Chronic Kidney Disease, Bacteriuria, Urinary Tract Infection, Acute Kidney Failure, Malignant Neoplasm of Rectum, Colostomy Status.R2's Minimum Data Set, MDS dated R2's MDS dated [DATE] documents R2 has no cognitive deficits. R2 is dependent for rolling, sitting and transfers. R2's baseline care plan dated 12/4/2025 documents The resident has Catheter: Neurogenic Bladder. Interventions include Catheter Care, Position catheter bag and tubing below the level of the bladder 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-03 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to keep a resident free from misappropriation of property related to a staff member's use of a resident's money, for 1 of 3 residents (R3) reviewed for misappropriation in a sample of 8. This failure resulted in R3 having money stolen from bank account and feeling unsafe, like a fool, stupid and like a target. This past non-compliance occurred on 7/9/24 to 7/17/2024. Findings include: R3's Minimal Data Set, dated 5/30/2024, documents that R3 is cognitively intact. The facility's investigation documents On 7/16/2024, resident (R3), notified her bank of inconsistencies with her bank account. She filed a report with the bank. The bank did an investigation and determined that two staff members made several transactions using (R3's) (mobile payment application). The bank notified (Local) Police Department (PD) (report #) (Local) PD notified the facility. Upon receiving the initial concern on 7/17/2024, we initiated an internal investigation in accordance 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the Physician prescribed skin/wound treatments for 1 of 6 residents (R5) reviewed for wounds and quality of care in the sample of 44. Findings include: 1. On 06/25/24 at 10:00 AM, R5 stated that he does get cellulitis in his abdomen often. R5 was questioned if he gets a treatment to his abdominal folds. R5 stated that he gets nystatin powder to his folds and to his groin. R5 was questioned if he gets any type of barrier disposable cloth placed in his abdomen to collect the moisture, he stated that he does not. On 6/25/24 at 3:00 PM, V3, Assistant Director of Nurses, (ADON), entered R5's room to look at his abdomen. R5 was questioned if he gets a disposable cloth to absorb the moisture between his folds, R5 stated, You mean InterDry? I used to, but I don't anymore. It's been a while since I had one. R5 was questioned if he knew why. R5 stated, It is kind of hard to get it in the fold because the fold is so large and heavy. R5…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-07-01 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to identify, assess, and implement interventions for pain for 1 of 6 residents (R129) reviewed for pain in the sample of 44. This failure resulted in R129 moaning in pain due to not being assessed and treated with pain medication for 44 minutes. Findings include: 1. On 6/24/2024 at 11:50AM R129 stated to V3 Assistant Director of Nursing (ADON) that her stomach was hurting. R129 was lying in bed groaning with facial grimacing. V3 told R129 that she would let her nurse know and left R129's room. On 6/24/24 at 12:10 PM R129 continued to groan while belching and stating, Oh God, I want to die. On 6/24/24 at 12:15 PM V7, Certified Nursing Assistant (CNA) entered R129's room to turn her on her left side. R129 stated, I'm hurting like I have to poop, please hurry for the nurse. V7, CNA stated she would notify R129's nurse now. V7 exited R129's room. V7 CNA was observed speaking with V6, Registered Nurse (RN) at the end of hall passing medications. V6 continued to do medication pass after being told R129 was in pain. 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
• Actual harm · Gcited before2024-05-29 · 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 monitor and treat a resident with the diagnoses of Diabetes Type 2 for one of 3 residents (R10) reviewed for quality of care, in the sample of 12. This failure resulted in R10 being hospitalized with Uncontrolled Diabetes Mellitus with an initial blood glucose of 614 in the emergency room (ER). Findings include: R10's Hospital emergency room (ER) Records, dated 5/22/24, documented that he had a history of insulin dependent diabetes mellitus and that he was admitted to the hospital on that date with the diagnoses of Acute on Chronic Renal Failure and Uncontrolled Diabetes Mellitus. Per the hospital records, R10's blood glucose level was 614 when he was in the ER. R10's Face Sheet, printed 5/23/24, documented that he was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus without complications. R10's Minimum Data Set (MDS) dated [DATE] documents he is moderately cognitively impaired and is dependent on staff for Activities 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
• Actual harm · Gcited before2023-07-27 · 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 Deficiency requires two deficient practice statements. A. Based on interviews and record review the facility failed to timely treat a urinary tract infection (UTI) for 1 of 6 residents (R17) review for urinary incontinent/(UTIs) in the sample of 42. This failure resulted in R17 having symptoms of UTI on 6/2/23, delay of physician notification and treatment, and subsequently being admitted to the critical care unit at the local hospital with diagnosis of UTI with septic shock. Findings include: R17's July 2023 Physician's Order Sheet (POS) documented R17 had diagnoses of long-term use of antibiotics, personal history of urinary tract infections, sepsis, unspecified organism, sever sepsis with septic shock, extended spectrum beta lactamase (ESBL). R17's Minimum Data Set, dated [DATE] documents that R17's Brief Interview of Mental Status score was a 14 which indicates R17 is cognitively intact. MDS documents that R17 is extensive assist of two people for toileting needs and is always incontinent. R17's Care Plan…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-17 · 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 prevent resident to resident abuse in 2 of 4 residents (R5, R6) reviewed for abuse in the sample of 17. Findings Include:1.On 4/15/26 at 1:50 PM, R5 was unable to recall any details of the alleged incident with R16. R5's Face Sheet, undated, documents R5 has the following diagnoses: Hemiplegia/Hemiparesis following CVA (Cerebral Vascular Accident), Bipolar Disorder, Weakness, and Cognitive Communication Deficit.R5's MDS (Minimum Data Set), dated 3/23/26, documents R5 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R5 is cognitively intact.R5's Progress Note, dated 1/19/26 at 4:51 PM, documents the following: SSD (Social Service Director) visited resident today. Resident stated that she has no trauma from the resident to resident. Resident stated that she just ignores the other resident now.On 4/15/26 at 2:35 PM, R16 stated she did hit and pull R5's hair, she shouldn't have done it, and she is sorry. R16 stated her and R5 get along…

  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 · F2025-06-26 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 a palatable meal to residents at the facility. This failure has the potential to affect all 79 residents residing at the facility. Findings include: 1. During resident council meeting on 6/24/2025 at 10:30 AM R26, R29 and R49 all stated their food is cold when served. R26's Minimum data set (MDS), dated [DATE], documents R26 is cognitively intact. R29's MDS, dated [DATE] documents R29 is cognitively intact. R49's MDS, dated [DATE], documents R49 is cognitively intact. The facility Resident Council Minutes, dated May 8, 2025, documents issues/concerns; food cold. The facility Resident Council Minutes dated June 3, 2025 documents issues/concerns: cold dinner and breakfast. On 6/24/2025 at 11:41 AM food temperatures obtained from steam table prior to first tray; rice 206 degrees, corn 188 degrees, mashed potatoes 152 degrees, gravy 140 degrees, corned beef 162 degrees. On 6/24/2025 12:52 PM during noon meal a test tray was obtained 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-06-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review and interview the facility failed to store food in a manner to prevent food borne illness. This has the potential to affect all 79 residents at the facility. Findings include: 1. On 6/23/2025 at 8:40 AM there was bowl of ice cream on the floor of walk in freezer. In the dry storage room, 2 boxes of apple juice unopened and 10 large cans of chicken noodle soup in the case were sitting on the floor. The white upright freezer in the dry storage room contained a open, unlabeled, and undated package of 8 turkey patties. A bag of chicken patties in the box that were opened and undated. The 3 compartment refrigerator in kitchen contained 2 single serving bowls of cottage cheese that were uncovered and undated. 3 lettuce salads with cheese covered with clear wrap that were undated. Next to salads on a plastic tray plastic was an individual container of salad dressing and a white condiment container of mayonnaise both were uncovered and not labeled. On 6/25/2025 at 12:20 PM V4, Dietary Manager stated can goods should not be stored on the floor an opened…

  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 · Ecited before2025-06-26 · tag F0550 — failed to protect resident dignity and rights — pattern
  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 6. During resident council meeting on 6/24/2025 at 10:30 AM R26, R29 and R49 all stated call lights are not answered timely. R26, R29 and R49 all stated it is worse on the night shift due to agency staff, and they are always on their phones. R26's MDS, dated [DATE], documents R26 is cognitively intact. R29's MDS, dated [DATE], documents R29 is cognitively intact. R49's MDS, dated [DATE], documents R49 is cognitively intact. The Facility Resident Council Minutes, dated April 1, 2025, documents issues/concerns: hall daily, lights. The Facility Resident Council Minutes, dated May 8, 2025, documents follow-up concern from last meeting; call light times. Based on interview and record review, the facility failed to answer call lights in a timely manner for 8 of 18 residents (R3, R26, R29, R48, R49, R53, R60, R174) reviewed for dignity in the sample of 43. Findings include: 1. On 06/23/25 at 10:30 AM, R48 stated, At night it can take up to an hour and a half for them to come in and answer the light. R48's Face Sheet,…

  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 · E2025-06-26 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  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 bathing, personal hygiene and documentation for 5 of 7 (R4, R8, R21, R36 and R224) residents, reviewed for activities of daily living, in a sample of 43. Findings include: 1.On 06/23/2025 at 02:47 PM R8's hair was greasy. On 06/24/2025 at 12:33 PM R8's hair was greasy. R8's Physicians order sheet, dated 6/25/2025, documented diagnoses of Alzheimer's Disease, and Type 2 diabetes mellitus. R8's Minimum data set (MDS) dated [DATE] documented that her cognition was severely impaired and was dependent upon staff for bathing and hygiene. R8's Care Plan dated, 3/11/2025, documented an intervention of BATHING: (R8) requires the assistance from one staff member to assist with bathing. R8's Local hospice documentation, dated for 4/2025 and 5/2025 did not document that received a shower or a bath from 4/7/2025 to 5/12/2025 per hospice documentation. There was no documentation of R8 receiving a shower or bed bath from the staff at 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 06/23/2025 at 09:30 AM, R4 was lying in bed, asleep, and her oxygen was on per nasal cannula. R4's oxygen tubing was not dated and there was not humidity bottle. R4's Physicians order sheet, dated 6/25/2025, documented diagnoses of Chronic obstructive pulmonary disease and Legal blindness. It also documented, Oxygen Tubing - Change Weekly every night shift, every Sun for maintenance. Oxygen - clean O2 concentrator filter with water and allow to air dry weekly. Every night shifts every Sun for maintenance. It also documented an order, 2L o2 via Nasal Cannula continuously R4's MDS, dated [DATE], documented that her cognition was intact. R4's Care Plan, undated, documented, (R4) has Oxygen Therapy r/t COPD 4. On 06/23/2025 at 08:36 AM, R22 was asleep in bed, and her oxygen was running, and the tubing was coiled up on the end of her bed, but it was not on her. R22's oxygen tubing was not labeled nor dated. On 06/23/2025 at 11:06 AM, R22 was lying in bed, awake, stated that she does not wear her oxygen all 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-26 · 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 3. On 06/23/2025 at 01:17 PM, V8, Activity Director, without benefit of hand hygiene, passed a lunch tray to R226. V8 set up R226's meal tray. She then exited R226's room into the hallway to the meal cart. 4. On 06/23/2025 at 01:19 PM, V8, Activity Director, without benefit of hand hygiene, then retrieved the meal tray for R224 and took it to his room. She set up his tray and explained what was on his tray. On 06/25/2025 at 10:50 AM, V28, LPN, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:52AM, V27, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:53 AM, V26, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:55 AM, V25, CNA, stated that hand sanitizer should be used in between residents when passing meal trays. On 06/25/2025 at 10:56 AM, V22, RN, stated that hand sanitizer should be used in between residents when passing meal…

  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 · E2025-06-26 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer pneumonia vaccines for 5 of 5 residents (R3, R7, R10, R53, R62) reviewed for vaccines in the sample of 43. Findings include: 1. R53's admission Record, print date of 6/24/25, documents R53 was admitted on [DATE] with diagnoses of Type 2 diabetes and Sleep Apnea. R53's Immunization Record fails to document R53 has had the pneumonia vaccine or declined the vaccine. 2. R10's admission Record, print date of 6/25/25, documents R10 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R10's Immunization Record fails to document R10 has had the pneumonia vaccine or declined the vaccine. 3. R3's admission Record, print date of 6/24/25, documents R3 was admitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. R3's Immunization Record fails to document R3 has had the pneumonia vaccine or declined the vaccine. 4. R62's admission Record, print date of 6/24/25, documents R62 was admitted on [DATE] with 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
• Potential for harm · Dcited before2025-06-26 · 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 prevent physical abuse for 1 of 1 resident (R67). This failure affects two residents (R43 and R67) reviewed for abuse in the sample of 43. Findings include: R43's Health Status Note, dated 4/25/2025 at 5:33 PM, documents, Note Text: Resident in dining area got up from sitting went to kitchen window picked up cup of thickened cold liquid. while walking back to her seat she threw out cup of liquids onto another resident (R67). (R67) was tended to and incident was witnessed by 2 kitchen helpers (V4) and (V23). R43 denies doing this upon questioning. (R67) received head to toe assessment without injury. Administrator was informed. R43's Abuse Final Report, dated 5/2/25, documents, On 4/25/25, (R43) was walking to the dish window in the dining room and poured her drink on (R67). Staff intervened and (R43) promptly returned to her seat. It continues, At conclusion of the investigation, based on staff statements, the incident did occur. On 6/25/25 at 9:20 AM,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide the physician with the pharmacy recommendation and to provide limitations or rationale for a physician ordered as needed anti-anxiety medication, for 1 of 3 (R56) residents reviewed for psychotropic medication review, in a sample of 43. Finding includes: R56's Physicians order sheet, dated 6/2025, documented diagnoses of Alzheimer's disease with late onset, Cognitive communication deficit, Neurocognitive disorder with Lewy bodies, Major depressive disorder, Generalized anxiety disorder and panic disorder. R56's Minimum Data Set, dated [DATE], documented that his cognition was severely impaired and that he has had no behaviors exhibited. R56's Care plan, dated 9/10/2024, documented, Monitor/document /report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. R56'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.

  Freedom from Abuse, Neglect, and Exploitation 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.

Fines & penalties

$137,709 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $137,709 — penalty dated 2024-05-29
• Medicare payment denial — starting 2024-06-21 for 69 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 TUTERA SENIOR LIVING & HEALTH CARE — 25 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 →

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

CMS files one row per role, so the 24 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

8 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.

This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in IL