Centralia Manor

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.

53.5% 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 256 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 41.9% 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 129 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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 120 beds and averages 73.2 residents a day — about 61% occupied, or roughly 47 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 4.48 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.05 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.72 hrs/resident/day on weekends vs 4.79 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.54 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% is below 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.

30 citations, most serious first. The 17 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · J2025-09-09 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 initiate cardiopulmonary resuscitation (CPR) timely for 1 of 3 (R1) residents reviewed for death in the sample of 11. This failure resulted in facility staff not initiating CPR for 10-15 minutes after finding R1, who had chosen to be a full code with full treatment, in bed with no pulse and no respirations. CPR was not initiated until V11 (RN/Registered Nurse) was told by oncoming staff that R1 was a full code. After CPR was initiated, R1 was transferred via ambulance to the local hospital and pronounced dead.This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when facility staff failed to immediately initiate CPR after finding R1 with no pulse and no respirations. This failure resulted in R1 who was without pulse and respirations not receiving CPR for 10-20 minutes. After CPR was initiated R1 was transferred to the local hospital by emergency services and pronounced dead shortly after arrival at the hospital.V1…

  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 · Past Non-Compliance
• Actual harm · Gcited before2026-02-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to keep residents free from abuse for 2 (R1 and R3) of 3 residents reviewed for abuse in a sample of 5. This failure would cause a reasonable person to experience feelings of fear, anxiety and anger while residing in their home.Findings include:1. R2's Face Sheet documents an admission date of 12/11/25 with diagnoses including: displaced fracture of upper end of right humerus, dementia, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, candidiasis of skin and nail, pain, vitamin D deficiency, major depressive disorder, and essential hypertension. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03 indicating R2 has severe cognitive impairment.R1's Face Sheet documents an admission date of 05/15/25 with diagnoses including: Alzheimer's disease, hypokalemia, altered mental status, major depressive disorder, anxiety disorder, seizures, type 2 diabetes mellitus, dementia, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-09-24 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to answer alternative call lights for residents needing assistance in a timely manner to promote dignity for 5 residents of 13 residents (R1, R2, R4, R6, and R7) reviewed for call light response in a sample of 13. This failure resulted in R1, R2 and R4 having bowel and bladder accidents which lead to feelings of humiliation, embarrassment and shame. Findings include: 1. R1's Face Sheet dated 09/23/25 documents an admission date of 08/21/25 with diagnoses in part of fusion of the spine lumbar region, muscle weakness, other rupture of muscle, spinal stenosis lumbar region, other specified local infection of the skin and subcutaneous tissue, anxiety, rheumatoid arthritis, overactive bladder, and unspecified injury at unspecified level of cervical spinal cord.R1's MDS (Minimum Data Set) dated 08/28/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates R1 is cognitively intact. Section GG documents toileting as set-up…

  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
• Actual harm · Gcited before2025-07-01 · 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, observation, and record review, the facility failed to consistently identify hazards/risks related to falls and ensure individualized, resident centered interventions were developed and implemented for prevention of falls for 4 of 7 residents (R13, R17, R28, R263) reviewed for accidents in a sample of 40. This failure resulted in R17 receiving a laceration to the back of the head, requiring emergency room treatment which included 3 staples to the back of R17's head. Findings include: 1. R17's Resident Face Sheet documented an admission date of 04/23/20 and included diagnoses of Alzheimer's disease, unspecified and difficulty in walking, not elsewhere classified. R17's MDS dated [DATE], documented a BIMS should not be completed, indicating R17 is rarely or never understood. Section GG-Functional Abilities documented that R17 requires partial/moderate assist with transferring. R17's Care Plan documented R17 is at risk for falls with interventions including emergency room evaluation on 03/01/25…

  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 before2025-07-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (R7 and R213) of 7 residents reviewed for nutrition in a sample of 40. This failure resulted in further contributing to continued harm for R7, who is documented to be severely underweight with a Body Mass Index of 16.66%. Findings include: R7's Resident Face Sheet documents an admission date of 01/30/2018 with diagnoses that included dementia, atherosclerotic heart disease, osteoarthritis, dysphagia, major depressive disorder, cachexia, pain in right arm, ventral hernia without obstruction or gangrene, abnormal weight loss, anxiety disorder, heartburn, vitamin deficiency, gastro-esophageal reflux disease without esophagitis, and vitamin B12 deficiency anemia. R7's Minimum Data Set (MDS) dated [DATE] documented no Brief Interview for Mental Status was performed due to resident is rarely/never understood. R7's eating ability is documented as setup or clean-up…

  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 · G2025-07-01 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure that pain management was provided for one (R53) of one resident reviewed for pain management in a sample of 40. This failure resulted in R53 experiencing prolonged severe pain without relief for several hours. Findings include: R53's Resident Face Sheet documented an admission date of 06/05/25 and included diagnoses of urinary tract infection, disorder of the skin and subcutaneous tissue, rash and other nonspecific skin eruption, muscle weakness, unilateral primary osteoarthritis in the left hip, pain, anxiety disorder, spinal stenosis in the lumbar region with neurogenic claudication, atrial fibrillation, and osteoarthritis. R53's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. R53's Care Plan documents a problem area with a start date of 06/05/25 of R53 has (or risk for) pain related to osteoarthritis and spinal stenosis 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-07-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide prescribed nutritional supplements and provide assistance with meals, and monitor intake for one of one resident (R20) reviewed for weight loss in a sample of 34. These failures resulted in R20 experiencing a severe and continuing weight loss (8.48%) within 3 months. The findings include: R20's Face Sheet, dated 07/11/24, documents R20 was admitted to the facility on [DATE] with diagnoses in part of chronic obstructive pulmonary disease, major depressive disorder, dysphagia, heartburn, dementia, cognitive communication deficit, dietary calcium deficiency, deficiency of other vitamins, pain, and hyperlipidemia. R20's Care Plan with a revised date of 05/16/24 documents under R20's Care information interventions of puree diet with super cereal at breakfast, fortified pudding at lunch/supper, and nutritional supplement at meals. There were no care areas listed for areas pertaining to nutrition or weight loss in the care plan. R20's…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-13 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure privacy was maintained for 1 (R1) of 3 residents reviewed for privacy in the sample of 6. Findings included:R1's Face Sheet documented an admission date to the facility on 7/26/2023 with the following diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, depression, unspecified, generalized anxiety disorder, other insomnia, and rapid eye movement sleep behavior disorder. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Score (BIMS) of 04 documenting R1 had severe cognitive impairment. Section I Active Diagnoses documented R1 has non-Alzheimer's dementia, anxiety, depression and psychotic disorder. R1's Care Plan documented a focus area of behavioral symptoms of depression and dementia without behavioral disturbances. R1 care plan documents R1 has delusions and becomes upset after family visits. R1 packs 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-13 · 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 observation, interview and record review, the facility failed to ensure residents were free from abuse by a staff member for 1 (R1) of 3 residents reviewed for abuse in the sample of 6. Findings included:R1's Face Sheet documented an admission date to the facility on 7/26/2023 with the following diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, depression, unspecified, generalized anxiety disorder, other insomnia, and rapid eye movement sleep behavior disorder. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Score (BIMS) of 04 documenting R1 had severe cognitive impairment. Section I Active Diagnoses documented R1 has non-Alzheimer's dementia, anxiety, depression and psychotic disorder. R1's Care Plan documented a focus area of behavioral symptoms of depression and dementia without behavioral disturbances. R1 care plan documents R1 has delusions and becomes upset after family…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-10 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report alleged abuse for 1(R2) of 3 resident reviewed for abuse allegations in a sample of 5.Findings include:R2's Face Sheet documents an admission date of 12/11/25 with diagnoses including: displaced fracture of upper end of right humerus, dementia, type 2 diabetes mellitus, muscle weakness, cognitive communication deficit, candidiasis of skin and nail, pain, vitamin D deficiency, major depressive disorder, and essential hypertension. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 03 indicating R2 has severe cognitive impairment.R1's Face Sheet documents an admission date of 05/15/25 with diagnoses including: Alzheimer's disease, hypokalemia, altered mental status, major depressive disorder, anxiety disorder, seizures, type 2 diabetes mellitus, dementia, and visual loss. R1's MDS dated [DATE] documents a BIMS score of 04 indicating R1 has severe cognitive impairment.R1's Care Plan documents 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent and investigate alleged abuse for 2 (R1 and R2) of 3 residents reviewed for abuse in a sample of 5.The findings include:R1's Face Sheet documents an admission date of 05/15/25 with diagnoses including: Alzheimer's disease, hypokalemia, altered mental status, major depressive disorder, anxiety disorder, seizures, type 2 diabetes mellitus, dementia, and visual loss. R1's MDS dated [DATE] documents a BIMS score of 04 indicating R1 has severe cognitive impairment.R1's Care Plan documents a problem area of: behavioral symptoms with goals listed as: R1 will have a decrease in other behaviors by next review dated 03/12/26 with approaches listed as help R1 to call her friend when restless dated 06/16/25 and offer R1 a snack and drink in room or dining area dated 05/19/25, R1 will have a decrease in verbal, physical and rejection of care behaviors by next review dated 03/12/26 with an approach listed as offer independent activity supplies and setup dated…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-09-24 · tag F0919 — failed to provide a working call system — pattern
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  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 functional call system for the 32 residents living on the 300, 400, and 500 halls.The findings include: 1. On 09/22/25 at 9:32AM, R1 stated that the call light system on her hall has been down almost since she was admitted to the facility. R1 said they gave her a bike horn to be able to get a hold of staff when she needs help. R1 said she thinks that staff can hear the horn most of the time. R1 said that other times she doesn't know if they can hear it. R1 said one time it took them 45 minutes to answer her horn. R1's MDS (Minimum Data Set) dated 08/28/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 14 which indicates R1 is cognitively intact. 2. On 09/22/25 at 12:45PM, R2 stated that the call light system has been down since she was admitted . R2 said that they give the residents, bells, horns and whistles to use when they need help, and it is a joke. R2 said that staff is so loud or playing music…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-09 · tag F0940 — failed to train staff — widespread
  Develop, implement, and/or maintain an effective training program for all new and existing staff members.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility was unable to provide reproducible evidence annual training was completed for all staff. This failure has the potential to affect all 66 residents currently residing at the facility. Findings Include: The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document specific annual training for all staff. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation annual training had been completed for all staff.The facility Policy 1.10 on Inservice Training revised on 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-09 · tag F0941 — widespread
  Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure staff were trained on effective communications. This has the potential to affect all 66 residents currently residing at the facility. Findings Include: The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document effective communication training for staff. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation effective communication training had been completed for all staff. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education opportunities…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-09 · tag F0942 — widespread
  Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on interview and record review the facility failed to ensure all staff were trained on resident rights. This has the potential to affect all 66 residents residing at the facility. Findings Include:The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document staff were trained on resident rights. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation staff had been trained on resident rights. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide continuing education opportunities and promote job satisfaction

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-09 · tag F0946 — widespread
  Provide training in compliance and ethics.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility was unable to provide reproducible evidence staff were trained on compliance and ethics. This failure has the potential to affect all 66 residents residing at the facility. Findings Include:The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document specific compliance and ethics training for all staff. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation compliance and ethics training had been completed for all staff. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2. To provide…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-09 · tag F0947 — failed to train nurse aides adequately — widespread
  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure required in-service training for CNA's (Certified Nursing Assistants) was completed. This has the potential to affect all 66 residents currently residing at the facility. Findings Include:The facility Resident Directory dated 9/3/2025 documents there are 66 residents currently residing at the facility. Review of the facility training/in-service records do not document specific the required annual in-service training for CNA's was completed. On 9/8/25 at 12:18 PM, V1 (Administrator) notified this surveyor via email they were unable to locate documentation the required CNA training had been completed. The facility Policy 1.10 on Inservice Training revised 2/25/19 documents, Policy: The facility shall provide an on-going inservice program designed to cover job skill, training, and on-going education. The Administrator shall coordinate inservice training and provide appropriate documentation to indicate time, program content, and personnel attending. Purpose: 1. To enhance the training capabilities of all personnel. 2.…

  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

“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

$200,263 in federal fines across 5 penalties. 1 Medicare payment denial on record.

• $62,080 — penalty dated 2026-02-10
• $17,345 — penalty dated 2025-08-20
• $40,108 — penalty dated 2025-08-20
• $32,094 — penalty dated 2025-07-01
• $48,636 — penalty dated 2024-07-12
• Medicare payment denial — starting 2025-10-11 for 24 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 UNLIMITED DEVELOPMENT, INC. — 10 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 10 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $852K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

Cost & finances

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