Lakeside Health & Rehab Center

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.

47.8% 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 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 48.3% 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 29 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 0.38 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 37% 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.

Staffing

How full it usually is: this home is certified for 95 beds and averages 49.2 residents a day — about 52% occupied, or roughly 46 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.12 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.87 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 2.72 hrs/resident/day on weekends vs 3.28 on weekdays — 17% thinner on weekends. RN hours go from 0.29 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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 unchanged from the previous inspection. 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.

37 citations, most serious first. The 17 most serious are shown; the remaining 20 are one tap away and print in full.

• Immediate jeopardy · J2025-09-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess, monitor, and provide interventions to prevent decannulation for a resident with known behaviors of self-decannulation; and failed to ensure that staff were provided tracheostomy recannulation education for extubation for 1 of 2 residents (R3) reviewed for tracheostomy in the sample of 2. The failure resulted in R3's self-decannulation of her tracheostomy which compromised R3's health status. R3 required emergency transfer to the local hospital on [DATE] and required two attempts at reinsertion of the tracheostomy and arterial line placement. After reinsertion of R3's tracheostomy by an ENT physician, R3 became hypoxic with oxygen saturation in the 80's and had increased work for breathing. R3's hospital records document R3 ultimately died on [DATE] with clinical impression of tracheostomy complications, cardiopulmonary arrest and heart block. R3's death certificate is pending investigation. This failure has the potential to affect…

  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 before2026-04-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review, the facility failed to report a fall timely, follow fall incident procedures, and use gait belts during transfers for 3 of 5 residents (R1, R2, R3); reviewed for Quality of Care in a sample of 6. This failure resulted in R2 being moved before a nurse's assessment and delayed treatment for that R2 succumbed multiple pelvic fractures from later requiring surgery. Findings include:1.R2's Facesheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, atrial fibrillation, anemia, and age-related osteoporosis prior to her fall.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact and required substantial/maximal assistance for toilet transfers and going from sitting to standing.Care Plan initiated 1/14/26 documented R2 was at risk for falls and included the following intervention, in part, for staff to encourage call light usage.R2's Fall Incident Investigation documented her fall occurred on 2/10/26 at 9:00 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, Interview, and Record Review the facility failed to implement preventative measures to reduce the development of and worsening of pressure injuries in 2 of 7(R55, R39) residents in the sample of 31. This failure resulted in R55's skin on 1/7/25 documented as mid buttocks maceration to a developed and documented sacrum pressure ulcer stage 3 on 1/16/25; and other in house developed pressure wounds. R39 also developed several in-house pressure injuries. Findings include: 1. R55's Face sheet documents an admission date of 1/7/2025. Diagnosis include Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Dysphagia, Type 2 Diabetes, Congestive Heart Failure. R55's Minimum Data Set, MDS, dated [DATE] documents R55 is moderately cognitively impaired. R55 is dependent for rolling left to right and chair to bed transfers. R55 is at risk for pressure injuries and has unhealed pressure injuries. R55's care plan updated 3/4/2025 documents Actual Pressure Ulcer; Site(s):…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation, and record review the facility failed to provide progressive interventions and to prevent multiple falls for 1 of 5 (R47) residents investigated for accidents in a sample of 31. The failure resulted in R47 sustaining a right hip fracture and then sustaining a right hip surgical incision dehiscence requiring a return to the hospital for sutures and antibiotics. Findings include: R47's EMR (Electronic Medical Record) undated documents that the resident was readmitted to the facility after right hip surgery on 12/04/24. R47's EMR dated 4/25/24 documents a diagnosis of unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified osteoarthritis, unspecified site; and age-related osteoporosis without current pathological fracture. R47's MDS (Minimum Data Set) dated 3/11/25 documents a BIMS (Brief Interview for Mental Status) score of 4 out of 15. The MDS documents that the resident requires substantial/maximal assistance for roll left and right, sit to lying, lying to sitting on side 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 before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent injury to R2's right second toe during transport to the facility from the hospital. This failure resulted in R2's right toe striking the plate at the bottom of door, causing a wound to the second toe of right foot and toenail being removed. Findings include: On 1/29/2025 at 12:40PM V13, Certified Nursing Assistant (CNA) removed socks from R2's feet. R2's second toe of right foot, toenail is off and area dried blood. No dressing in place as verified by V13. On 1/29/2025 at 10:55AM V14, facility transport stated she provided transport for R2 from hospital in (town name) to the facility on 1/15/2025. V14 stated when pushing R2 into the facility R2's foot hit the plate at the bottom of the door. V14 stated it was bleeding and she notified the nurse. On 1/29/2025 at 12:50PM V8 Licensed Practical Nurse (LPN) stated she was on duty when R2 arrived at the facility on 1/15/2025. V8 stated R2's toenail was off and bleeding. V8, LPN 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to prevent, identify, assess, monitor, implement progressive interventions, and to handle soiled pressure ulcer dressings appropriately to prevent pressure ulcers and encourage healing for 2 of 3 residents (R2, R3) reviewed for pressure ulcers in the sample of 6. This failure resulted in R2 going for 9 days without a treatment in place for a left heel pressure ulcer and R3 having one pressure ulcer on the left medial foot that was unknown by staff, one pressure ulcer on the left great toe that did not receive treatment or a full assessment for 9 days and R3 developing osteomyelitis requiring Intravenous Antibiotics. Findings include: 1. On 9/3/24 at 8:41 AM, V7, Certified Nurse's Aide (CNA) and V8 CNA are in R3's room in the middle of cleaning her up. R3 is lying on her left side. R3 has a visible sacrum pressure ulcer approximately 4 inches (in) by (x) 3 in x 2.5 in deep. The old dressing has yellow brown drainage on it. The dressing is 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 · G2023-04-14 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 Physician's hospital discharge orders for a high-risk anticoagulant medication for 1 of 2 residents (R49) reviewed for anticoagulant medications in the sample of 27. This failure resulted in R49 receiving double the ordered dose of Eliquis for three days and being hospitalized for 11 days with the diagnosis of Severe Blood Loss Anemia, Acute on Chronic with a differential diagnosis of GI (Gastrointestinal) Bleed, AAA (Abdominal Aortic Aneurysm), and Autolysis. Findings include: R49's Face Sheet documents, R49 was admitted to the facility on [DATE], with the diagnoses to include: Embolism and Thrombosis of Lower Extremities, Other Long Term (Current) Drug Therapy, Anemia, and Paroxysmal Atrial Fibrillation. R49's Hospital Discharge Orders dated 02/24/23 documents, the following order: Eliquis 2.5 mg, (milligram), give 5 mg every 12 hours. R49's Facility Physician Order Summary Report, dated 02/24/23 documents, the order dated 02/24/23: Apixaban…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-05-26 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 a sufficient number of CNAs (Certified Nursing Assistants) to provide timely care to the residents in the sample of 29, when reviewed for sufficient staffing. This failure has the potential to affect all 54 residents residing in the facility.Findings Include:On 5 /19/26 at 9:36 AM, R7 pressed the call light button due to being incontinent of urine. R7 stated she is unsure how long she was been wet because she fell asleep, but she is wet now. R7 stated she is left in a wet depends for extended periods of time and has waited over 30 minutes for her call light to be answered by staff to help her. On 5/19/26 at 9:40 AM, V22, Activity Aide, walked into R7's room and asked what R7 needed. V22 walked out of R7's room with R7's call light still on.On 5/19/26 at 9:47 AM, V14, CNA, entered R7's room and turned off the call light. V14 took R7's clothes out of R7's closet and turned on the water from R7's sink.On 5/19/26 at 9:49 AM, V14 walked out of R7's room and left the faucet water running. R7 stated this is…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-26 · 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 provide timely emergency room (ER) transport for 1 of 1 residents (R61) reviewed for quality of care in the sample of 29. This failure resulted in R61 not being sent to the ER for more than eight hours after receiving the physician order. R61 decompensated later that day and required oral intubation.Findings include: 1-R61's Face Sheet documents R61 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV), toxoplasma meningoencephalitis, cryptococcosis, and streptococcal pneumonia. R61's Minimum Data Set (MDS) dated [DATE] documented R61 was cognitively intact and required partial assistance with bed mobility and transfer. 05/20/2026 10:03 AM, R61 was sitting up in his bed. He was very thin with orbital wasting. He stated he did not receive his IV medications in the Facility for a couple of days on admission and ended up in the ICU (Intensive Care Unit). R61's Physician Order dated 4/23/26 documents Ganciclovir…

  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 before2026-05-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide appropriate nephrostomy care to prevent infections in 1 of 2 residents (R10), reviewed for bowel/bladder incontinence, catheters, and UTIs (Urinary Tract Infections) in the sample of 29. This failure resulted in R10 having multiple UTIs with hospitalization. Finding Include:On 5/20/26 at 10:40 AM, nephrostomy care was observed with V21, Wound Nurse, with the following noted: Prior to entering room, V21 donned a gown, gloves, and mask. V21 entered the room and removed the left nephrostomy dressing, dated 5/19/26, and discarded it in the regular trash can. There were no gloves available in the room, V21 exited the room and brought in a box of gloves. V21 donned the gloves with no hand hygiene completed. V21 then proceeded to clean the nephrostomy tube on the left injection site and flushed it with normal saline as ordered. V21 then cleaned the injection site again and removed her gloves. V21 then donned new gloves without completing hand hygiene. V21 then cleaned around the left nephrostomy tube site,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-26 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  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 obtain and properly administer prescribed medications for 2 of 3 residents (R15, R61) reviewed for pharmacy services in the sample of 29. This failure resulted in R61 missing three doses of a prescribed intravenous (IV) medication and being transported to the hospital where he required intubation.Findings include: 1-R61's Face Sheet documents R61 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV), toxoplasma meningoencephalitis, cryptococcosis, and streptococcal pneumonia. R61's Minimum Data Set (MDS) dated [DATE] documented R61 was cognitively intact and required partial assistance with bed mobility and transfer. On 5/20/2026 at 10:03 AM, R61 stated he did not get his IV medications for a couple days when he was admitted to the Facility and ended up in the ICU (Intensive Care Unit). R61's Hospital Discharge Paperwork dated 4/23/25 documents R61 received a dose of Ganciclovir 7 milliliter (mL) IV…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-26 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to utilize infection control techniques in 5 of 5 residents (R3, R7, R10, R15, R28), reviewed for infection control in the sample of 29. This failure resulted in R10 having multiple UTI's (Urinary Tract Infections) with hospitalization. Findings Include: 1) On 5/20/26 at 10:40 AM, nephrostomy care was observed with V21, Wound Nurse, with the following noted: Prior to entering room, V21 donned a gown, gloves, and mask. V21 entered the room and removed the left nephrostomy dressing, dated 5/19/26, and discarded it in the regular trash can. There were no gloves available in the room, V21 exited the room and brought in a box of gloves. V21 donned the gloves with no hand hygiene completed. V21 then proceeded to clean the left nephrostomy tube injection site and flushed it with normal saline as ordered. V21 then cleaned the injection site again and removed her gloves. V21 then donned new gloves without completing hand hygiene. V21 then cleaned…

  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 before2025-11-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a safe transfer for 1 of 1 resident (R6) reviewed for accidents in the sample of 16. Findings include:R6's admission Record, print date of 10/2/25, documents R6 was admitted on [DATE] and has diagnoses of Alzheimer and Dementia.R6's Minimum Data Set, dated [DATE], documents R6 is severely cognitively impaired, uses wheelchair, is dependent on staff for toileting, showers, lower body dressing, personal hygiene, and all mobility except rolling in bed.R6's Care Plan, dated 12/12/23, documents, (R6) has a Self-Care Deficit As Evidenced by: Needs assistance with ADLs (Activities of Daily Living) related to dx (diagnosis): ALZHEIMER'S DISEASE, UNSPECIFIED, HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE. Intervention: Transfer: Two person physical assistance required Date Initiated: 12/13/2024.R6's Therapy to Nursing Recommendations, dated 8/21/25, documents R6 transfers with assist of 2 with a wheeled walker.R6's Health Status Note, dated 9/3/2025…

  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 before2025-06-11 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  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 maintain residents' well-being and dignity by accommodating preference for 4 of 5 residents (R1, R2, R4, and R5) reviewed for accommodation of needs in the sample of 6. Findings include: On 6/6/2025 at 9:14 AM, R4 stated, the facility runs out of towels, pads and sheets all the time. I think they need to order more. They are always running out. It happens a lot, too much. I have my own briefs that I keep at my bedside, but staff had come in here and taken mine. I get cold sometimes and they do not have enough blankets and when I ask, they say they do not have any more. On 6/6/2025 at 9:18 AM, R2 stated the Facility at night runs out of adult briefs and pull ups at least two or three times a month. On 6/6/2025 at 9:28 AM, R5 stated the Facility has run out of (adult diapers) and staff made her stay in her room when she did not want to because they did not have anything to put on her. On 6/6/2025 at 10:29 AM, V8, Certified Nursing Assistant (CNA) stated, I started working in the Facility as a housekeeper and then…

  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 · Fcited before2025-03-28 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 provide sufficient nursing staff to meet the needs of the residents residing in the facility when reviewed for Sufficient Staffing in the sample of 31. This failure has the potential to affect all 62 residents residing in the facility. Findings include: 1. On 3/25/25 at 12:20 PM, R4 stated they need more CNAs (Certified Nursing Assistants) everyday, all day. R4 stated the CNAs are leaving and not staying. R4 stated she is constantly having to wait for her call light to be answered and care provided. R4 stated she has had to sit in her urine for long periods of time and she is tired of it and is trying to move to another facility. R4's MDS (Minimum Data Set), dated 2/5/25, documents R4 has a BIMS (Brief Interview of Mental Status) score of 15, indicating R4 is cognitively intact and is dependent with toileting. 2. On 3/25/25 at 9:35 AM, R2 stated there were only 2 CNAs on 3/22/25 during the night for the entire building. R2 stated it is harder to get care…

  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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-03-28 · tag F0761 — failed to label and store drugs safely — widespread
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to date two opened multi-dose vials of Tuberculin Serum when reviewed for medication storage and labeling. This failure has the potential to affect all 62 residents residing in the facility. Findings include: On 3/25/25 at 1:39 PM, the medication storage room refrigerator was observed with two multi-dose vials of Tuberculin Serum, opened and undated. The Tuberculin Product Information, dated October 2021, documents a vial of Tubersol (Tuberculin) which has been entered (opened) and in use for 30 days should be discarded. The Medication Storage Policy, dated 7/1/23, documents the facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. Medications shall be administered prior to the manufacture's expiration date. On 3/26/25 at 3:21 PM, V2, Director of Nurses, stated if the Tuberculin Serum is a multi-dose vial, it is used on multiple residents and should be dated when opened. The CMS (Centers for Medicare and Medicaid Services) for 671,…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-03-28 · tag F0576 — isolated
  Ensure residents have reasonable access to and privacy in their use of communication methods.
  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 opened a package belonging to a resident without their permission for 1 of 3 residents (R2) reviewed for Communication with Privacy in the sample of 31. Findings include: On 3/25/25 at 9:35 AM, R2 stated he had ordered a wireless charger and when it came, staff (unknown) opened the package prior to giving it to him without his permission because they thought it was medication. R2 stated he tells the staff when he has ordered something, so they don't open it and he does not order his medication anymore, the facility does. R2's Minimum Data Set, dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R2 is cognitively intact. R2's admission Contract, dated 12/20/24, documents R2 declined authorization for the facility to inspect and open official correspondence. On 3/26/25 at 8:58 AM, V1, Administrator, stated V1 the resident's mail/packages are not opened by staff. On 3/26/25 at 3:21 PM, V2, Director of Nurses, 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.

  Resident Rights 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

$251,582 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $108,500 — penalty dated 2026-04-15
• $104,706 — penalty dated 2025-09-10
• $27,583 — penalty dated 2025-03-07
• $10,793 — penalty dated 2025-01-30
• Medicare payment denial — starting 2026-05-05 for 40 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 SUMMIT HEALTHCARE CONSULTING — 9 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 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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 $295K 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