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Three Springs Sr Living & Rhab

161 Three Springs Road, Chester, IL 62233 · For profit - Limited Liability company · 83 certified beds · (618) 826-3210 Medicare & Medicaid certified

Call the home — (618) 826-3210 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (65%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2319 Old Plank Rd · (618) 826-2388 · Call to confirm hours
Pharmacy
2323 Old Plank Rd · (618) 826-2511 · Call to confirm hours
Grocery
806 Lehmen Dr · (618) 826-4564 · Call to confirm hours
Park
3402 Bodes Ln · (618) 826-1430 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.6%13.4%15.4%worse
Long-stay residents who lose too much weight3.1%6.3%5.4%better
Long-stay residents with a catheter left in their bladder1.5%0.9%0.9%worse
Long-stay residents with a urinary tract infection3.6%1.5%2.0%worse
Long-stay residents with depressive symptoms2.0%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.5%3.1%3.3%typical
Long-stay residents whose ability to walk worsened26.8%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.1%18.3%18.9%typical
Long-stay residents given the seasonal flu vaccine89.7%91.8%95.3%typical
Long-stay residents with pressure ulcers1.6%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control21.4%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.5%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine40.9%63.1%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.362.021.67better
Long-stay outpatient ER visits per 1,000 resident days2.572.221.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

29.5% 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 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

29.5%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
0.15U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF29.5%CMS range 19.9–41.851.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 6.2–16.510.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay4.3%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 3.1–11.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.25
RN hours/ resident / day
0.89
LPN hours/ resident / day
1.77
Aide hours/ resident / day
2.91
Total nurse hours/ resident / day
0.18
RN hoursweekends
65.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 83 beds and averages 65.0 residents a day — about 78% occupied, or roughly 18 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.77 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 2.71 hrs/resident/day on weekends vs 2.99 on weekdays — 10% thinner on weekends. RN hours go from 0.28 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-09-16)
2
at the previous standard inspection (2024-06-14)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited beforedisputed · IDR2025-09-03 · 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 supervise a moderately impaired resident with a history of stroke. R3 was left unattended outside and fell from the wheelchair for 1 of 3 residents (R3) reviewed for falls in the sample of 6. This failure resulted in R3 being sent to the hospital after sustaining a black eye and bruising to her forehead from the fall. Findings include: R3's Physician Order Sheet for August 2025 documents diagnosis of atherosclerotic heart disease, cerebral infarction due to thrombosis of left middle cerebral artery, unsteadiness on feet, weakness, need for assistance with personal care, lack of coordination, other abnormalities of gait and mobility, muscle weakness, hemiplegia and hemiparesis following cerebrovascular disease affecting unspecified side. R3's Minimum Data Set (MDS) dated [DATE] document she is moderately impaired for cognition for activities of daily living. She has impairment on one side on both her upper and lower extremities and uses 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-10 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that residents had a clean and sanitary shower/restroom and paper towels in residents' rooms and shower/restrooms for 51 (R1-R5, R8-R12, R15-R37, R39-R55) of 55 residents reviewed for clean showers/restrooms and supplies in a sample of 55. The Findings Include:On 6/7/26 at 8:32 AM, V3 (Licensed Practical Nurse/LPN) stated that when supplies run low typically a staff member just runs up to the local grocery store to get what is needed to get by until the next delivery date. On 6/7/26 at 9:41 AM, V4 (Housekeeper) stated that they have been out of paper towels in the shower room on C Hall for the past couple days. V4 stated that they do occasionally have an issue of running out of items and someone will run up the local store to grab what they need. On 6/7/26 at 10:04 AM, V5 (Certified Nursing Assistant/CNA) stated that in the past when supplies are low/out the staff go on their own to the local stores to get what they need and do not always get paid back. V5 went on to state that no one had went to get…

    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 before2026-06-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure incontinence care was provided timely for 2 of 3 (R6 and R8) reviewed for activities of daily living (ADL) in the sample of 24.Findings Include: 1. R6's admission Record with a print date of 6/7/26 documents R6 was admitted to the facility on [DATE] with diagnoses that include heart failure, chronic kidney disease, weakness, edema, history of urinary tract infections, pain, and unsteadiness on feet.R6's Minimum Data Set (MDS) dated [DATE] documents R6 has a Brief Interview for Mental Status score of 12, indicating a moderate cognitive deficit. This MDS documents R6 requires partial/moderate assistance with toilet hygiene and toilet transfer.R6's current Care Plan includes a Focus area, (R6) is at risk for Self care deficit. Date Initiated: 12/06/2024. This Focus area includes the intervention of, Assist with toileting and showers/bath. Date Initiated: 12/06/2024. This Care Plan includes a Focus area of, The resident has a chronic Urinary Tract…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-18 · 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 ensure medication errors did not occur for 1 of 3 residents (R6) reviewed for medication errors in the sample of 9. Findings include: R6's Physician Order Sheets (POS) for August 2025 documents a diagnosis of unspecified convulsions. The POS does not include a diagnosis of seizures or epilepsy. R6 has an order for carbamazepine ER (extended release) oral tablet 400 milligrams (mg) give 1 tablet by mouth two times a day for seizures, and phenytoin sodium extended capsule 100 mg, give 2 capsules by mouth two times a day for seizures, and 750 mg of methocarbamol, 1 tablet three times a day for muscle spasms. R6's Minimum Data Set (MDS) dated [DATE] document R6 was cognitively intact for decision making of activities of daily living and he was documented as having Seizure disorder or epilepsy. R6's Care Plan with a created date of 5/30/2025 documents R6 hasseizure activities. Interventions Give medications as ordered. Monitor/document for effectiveness 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-09-16 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 66 residents residing in the facility. Findings Include: The facility schedule dated August 11, 2025 through September 11, 2025 was reviewed and on 8/9/25, 8/27/25, 8/29/25, 9/1/25, 9/3/25, 9/6/25, 9/7/25 and 9/8/25 the facility did not have an Registered Nurse providing resident care for 8 Consecutive hours. On 9/12/25 at 9:00 AM V3 (Infection Preventionist) stated she completed the working schedules for the facility, and she scheduled what staff was available. At the time the facility only had 1 Registered Nurse. On 9/12/25 at 9:15 AM V2 (Director of Nursing) stated she was new to the facility and understands that the facility has been unable to provide Registered nurse coverage in the past. However, she has been providing coverage on her off days when the facility has not been able to find Registered Nurse coverage. On 9/12/2025 at 10:00 AM V1 (Administrator) stated the facility…

    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 before2025-09-16 · 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 interview and record review, the Facility failed to store foods in a manner that prevents foodborne illness. This has the potential to affect all 66 residents living in the Facility.Findings include:On 9/9/25 at 11:30 AM, in the standing refrigerator in the main kitchen, there was a container labeled tartar sauce with the date 8/29. There was a container labeled banana pudding and a pitcher labeled CB (cranberry) juice that were both labeled 9/2. There were two containers, each with 28 individual cups of various colored liquids that were not labeled or dated. V12 (Dietary Aid) stated leftover food items should be thrown out after three days.On 9/12/25 at 2:30 PM, V1 (Administrator) stated she expects staff to follow dietary policies regarding labeling, dating and discarding items after 7 days.The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy dated 2016 documents, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Discard food that has passed the expiration date, and discard food that…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-09-16 · tag F0800 — pattern
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    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 and interview, the Facility failed to ensure adequate food was prepared for 5 of 5 residents (R10, R24, R51, R57, R63) reviewed for food and nutrition services in the sample of 60.Findings include:On 9/9/25 at 12:40 PM, V11 (Cook) was scraping the bottom of the pan of chili on the steam table. She asked, Do we think (R57) is going to eat this? V3 (Infection Preventionist/IP), stated, We will see when we take it down there to her (in her room). V11 continued to scrape the pan and was able to fill the bowl about half full. V3 stated, She wanted a grilled cheese yesterday, so maybe give her that and a little bit of chili. V11 stated sometimes we do run out of food and have to offer them something else.On 9/9/25 at 12:45 PM, meal service was complete. There was not enough remaining chili or peas to obtain temperatures.On 9/9/25 at 12:50 PM, V12 (Dietary Aid) stated sometimes the kitchen runs out of food because of the budget. The Facility is always removing items from our food order after we…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-16 · 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

    Based on interview, observation and record review the facility failed to ensure that Fentanyl patches were removed from 1 of 3 residents (R75) from a sample of 25 as ordered by the physician. Findings include:R75's Face sheet undated documents an admittance date of 9/8/25 with pertinent medical diagnoses of Unspecified Acquired Deformity of Right Lower Leg and Unspecified Osteoarthritis, unspecified site. R75's Physician Order Summary dated September 2025 documents pain medications as Fentanyl Transdermal Patch 72 hour 37.5 Micrograms/hour (Fentanyl), Celebrex Oral Capsule 200 Milligram Daily, Voltaren External Gel 1 % every 8 hours, as needed, Tramadol 50 Milligram every 6 hours and Tylenol oral tablet 325 Milligram x's 2 three times day. On 9/11/25 at 10:11 AM V13 (Granddaughter of R75) stated while her grandmother was in physical therapy, she discovered that her grandmother had three (3) Fentanyl patches on her back. Two (2) were on the right shoulder and the third patch was on her left shoulder. The Director of Nursing did remove two (2) patches from R75's left shoulder. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-05 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed ensure a safe discharge for 1 of 3 residents (R1) reviewed for proper discharge in the sample of 12. This failure resulted in R1 being discharged to her home on 7/19/25 without her physician's knowledge, order, or consent. Findings include: R1's Physician Order Sheets (POS) for July 2025 document a diagnosis of closed fracture with routine healing, unsteadiness on feet and other abnormality of gait and mobility, weakness, chronic kidney disease stage 3, encounter for other orthopedic aftercare. R1's POS also document R1 was admitted to the facility on [DATE]. R1's Hospital Discharge papers dated 6/23/2025 document R1 with a diagnosis of ORIF (open reduction internal fixation) of right ankle. R1 has an order for non-weight bearing. R1's Minimum Data Set (MDS) dated [DATE] documents R1 was cognitively intact for decision making of activities of daily living. R1 requires partial/moderate assistance to walk 10 feet, toilet transfer; command to step up on curb…

    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 · Ecited before2025-08-13 · 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 ensure that residents who require assistance receive a shower or bath for 4 of 4 residents (R2, R8, R10, R11) reviewed for Activities of Daily Living assistance in the sample of 15. Findings Include: 1.R8's admission record, print date of 8/12/25, documented R8 has diagnoses including osteoarthritis, spinal stenosis, spondylosis of cervical region, depression, hypertension, bipolar disorder, schizophrenia, polyneuropathy, and intervertebral disc degeneration. R8's MDS (Minimum Data Set), dated 5/20/25, documented R8 is cognitively intact and requires partial to moderate assistance with bathing. R8's care plan, undated, documented R8 has an ADL (activities of daily living) self-care performance deficit impaired balance, requires assistance of 1 for transfers, and for bathing. On 8/11/25 at 9:40 AM R8 stated the facility does not have enough staff especially CNAs (Certified Nursing Assistants) and she has not been getting 2 showers a week…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-13 · tag F0725 — failed to have enough nursing staff — pattern
    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 observation, interview, and record review the facility failed to provide enough nursing staff to adequately meet the needs for 4 of 4 (R2, R8, R10, and R11) residents reviewed for staffing in the sample of 15. These failures have the potential to affect all residents residing at the facility. Findings Include: 1. 1. R8's admission record, print date of 8/12/25, documented R8 has diagnoses including osteoarthritis, spinal stenosis, spondylosis of cervical region, depression, hypertension, bipolar disorder, schizophrenia, polyneuropathy, and intervertebral disc degeneration. R8's MDS (Minimum Data Set), dated 5/20/25, documented R8 is cognitively intact and requires partial to moderate assistance with bathing. R8's care plan, undated, documented R8 has an ADL (activities of daily living) self-care performance deficit impaired balance, requires assistance of 1 for transfers, and for bathing. On 8/11/25 at 9:40 AM R8 stated the facility does not have enough staff especially CNAs (Certified Nursing…

    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
Show the remaining 12 citations
  • Potential for harm · Dcited before2025-08-13 · 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

    Based on observation, interview, and record review the facility failed implement fall interventions as care planned for 1 of 3 residents (R5) reviewed for falls in the sample of 15. Findings Include:R5's admission record, print date of 8/7/25, documented R5 has diagnoses including metabolic encephalopathy, orthostatic hypotension, chronic atrial fibrillation, atherosclerotic heart disease, hypothyroidism, hyperlipidemia, major depressive disorder, cognitive communication deficit, hypertension, urine retention, and a history of falling. R5's MDS (Minimum Data Set), dated 7/25/25, documented R5 is moderately cognitively impaired and requires supervision or touching assistance with transfers. R5's progress note, dated 8/3/25 at 4:20 PM, documented resident got herself up (and was) unattended in the dining room, her alarm sounded, and she was on the floor, fall witnessed, and no head involvement. R5's progress note, dated 8/8/25 at 3:49 PM, documented staff call this LPN (Licensed Practical Nurse) to DR (dining room), upon entering DR resident was noted sitting on her buttocks in front…

    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 · Fcited before2024-12-13 · tag F0880 — failed to prevent and control infections — widespread
    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 ensure staff were encouraging COVID-19 positive residents to wear masks and ensure staff don proper personal protective equipment (PPE) to prevent the spread of COVID-19. This has the potential to affect all 63 residents living in the facility. Findings include: 1. The COVID list documents R6 with an onset date of 12/2/2024. R6's Physician Order Sheet for 12/2024 documents a diagnosis of Other specified disorder of kidney and ureter, COVID 19 (12/2/2024), urinary tract infection, unspecified dementia. unspecified severity without behavior disturbances, psychotic disturbances, mood disturbances, GERD, Abnormal weight loss, hypoosmolality and hyponatremia, major depression, insomnia, hypothyroidism. depression, and essential hypertension. On 12/10/2024 at 8:44 AM, R6's Room has a tub of Personal Protective Equipment (PPE) outside of her door with a sign which documents, Droplet Precautions. The sign documents, Everyone must clean their…

    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 · Fcited before2024-11-19 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was working in the facility for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 66 residents living in the facility. Findings include: On 11/12/2024 at 9:04 AM, Staffing schedules were requested from the facility for the past 14 days. On 11/14/2024 at 9:33 AM, staffing schedules were reviewed and does not document any RN working on Wednesday 10/30/2024, Thursday 10/31/2024, Saturday November 2, 2024, Sunday November 3, 2024, and Monday 11/4/2024. Five of the 14 days reviewed does not documents any RN coverage. On 11/14/2024 at 2:45 PM, V1 (Administrator) stated, We have a census of 66 residents. I did not realize the RN coverage for the Director of Nursing only counted as half. We have another RN that works but she did not work this past weekend. V2 (Director of Nursing) did not work last weekend either. On 11/13/2024 at 2:55 PM, V2 (Director of Nursing) stated that currently the facility has two RN's me and V20 (RN). I know they are trying to…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-19 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    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 infection control surveillance was being followed for residents experiencing vomiting and/or diarrhea. This has the potential to affect all 66 residents living in the facility. Findings include: On 11/12/2024 at 9:35 AM, V1 (Administrator) stated, they had a few residents that were experiencing vomiting and diarrhea a few weeks ago but they were good now. On 11/13/2024 at 2:32 PM, V3 (Infection Control Specialist) stated, I started working here on 10/25/2024. I have not taken the course yet and do not have my certification. We have a census of 66 and we had 11 residents experience emesis and/or loose stools. Of those eleven residents three were sent out to the hospital. I reached out to Corporate, and they told me to test everyone for flu and COVID which I did, and everyone was negative. I was never instructed to put anyone on contact isolation and/or notify the health department. I did not do any surveillance and/or tracking my rooms. Staff members also got whatever it was, and I personally was really sick, but it…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-19 · tag F0676 — failed to keep up residents' daily-living abilities — pattern
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure resident showers were being given for 4 of 5 residents (R2, R3, R6 and R12) reviewed for activities of daily living in the sample of 13. Findings include: 1) R2's Physician Order Sheet (POS) for November 2024 documents a diagnosis of atherosclerotic heart disease, obesity, hemiplegia, and hemiparesis following cerebral infection affecting left non-dominate side, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene. R2's MDS dated [DATE] documents R2 was cognitively intact for decision making of activities of daily living. R2 has no impairment on the upper and lower extremity and uses a wheelchair. R2's Care Plan documents R2 has bladder incontinence. R2 has an ADL (activities of daily living) self-care performance deficit and has limited physical mobility. On 11/12/2024 at 12:47 PM, R2 stated, I know I am supposed to get two showers a week and I only got one shower last week. I think they need more help because I did not…

    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 · Fcited before2024-10-29 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, 7 days a week. This has the potential to affect all 70 residents living in the Facility. Findings include: The Facility's Nurse's Schedule does not document a RN was scheduled for at least eight hours on 10/12/24, 10/13/24, 10/19/24, or 10/20/24. On 10/25/24 at 3:18 PM, V1 (Administrator) stated the Facility did not have a RN for at least eight hours on 10/12/24, 10/13/24, 10/19/24 or 10/20/24. On 10/25/24 at 9:25 AM, V2 (Director of Nursing), stated there can be problems with staffing due to call offs and the Facility is actively recruiting staff. On 10/25/24 at 9:50 AM, V1 stated the Facility is trying its best to recruit nurses, but it is difficult in a rural setting when the Facility does not use agency staffing. On 10/29/24 at 8:50 AM stated the Facility does not have a policy on RN staffing and follows the federal regulations. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 10/29/24…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-29 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 respect end of life wishes for 1 of 3 residents (R2) reviewed for advanced directives in the sample of 4. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus type 2, chronic kidney disease stage 3, liver cirrhosis, heart failure, and chronic venous hypertension. R2's Undated Care Plan documents R2 has chosen DNR (Do Not Resuscitate) as advanced directives for end-of-life plan. R2's Progress Note by V12 (Social Services Director/SSD) on [DATE] documented R2 wished to be a DNR with comfort focused care, and R2's IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form was completed with R2 and sent to physician for signature. R2's POLST Form signed by V13 (R2's Physician) on [DATE] documents, No CPR (Cardiopulmonary Resuscitation): Do Not Attempt Resuscitation (DNAR). R2's Physician Orders document [DATE] orders for both Full Code and DNR. R2's Progress Note by…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-14 · 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, interview, and record review, the Facility failed to store foods in a manner that prevents foodborne illness. This has the potential to affect all 66 residents living in the Facility. Findings include: On 6/11/24 at 9:17 AM, there were crumbs on the bottom shelf of the serving counter and the bottom shelf of the food preparation area. The oven handles were sticky to the touch. On 6/11/24 at 9:20 AM, the standing refrigerator had a plastic bag with julienned zucchini that was not labeled or dated. There was a container holding various colored cups of individual liquids that were not labeled or dated. There were two opened containers of whipped cream with frosting tips that were lying on the shelf and were not re-wrapped or dated upon opening. There was a container of unlabeled fruit that was dated 6/2/24. On 6/11/24 at 9:20 AM, the deep freezer in the dry storage room contained a package of chicken breasts that had been opened, but were not resealed upon opening, leaving the contents open to air. The package was not labeled or dated upon opening. On 6/11/24 at…

    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 · D2024-06-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to attempt Gradual Dose Reductions on psychotropic medications for 1 of 3 residents (R23) in a sample of 10. Findings include: R23's face sheet from EHR (electronic health record) dated on 6/14/024 noted that R23 was admitted on [DATE] with diagnoses of: Chronic obstructive pulmonary disease, unspecified, cerebral infarction, unspecified, encounter for palliative care, type 2 diabetes mellitus without complications; unspecified psychosis not due to a substance, insomnia, unspecified, Alzheimer's Disease, unspecified dementia, with psychotic disturbance, specified anxiety disorders, major depressive disorder, single episode, essential hypertension, chronic ischemic heart disease, gastroesophageal reflux disease without esophagitis, hypoxemia, chronic pain acute kidney failure, headache, diverticulosis of both small and large intestine without perforation or abscess without bleeding, benign prostatic hyperplasia without lower urinary tract symptoms. R23'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2025-09-16 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 and interview, the facility failed to provide 80 square feet of floor space per resident bed for 53 out of 53 residents (R1, R2, R3, R4, R5, R7, R8, R10, R11, R12, R14, R17, R18, R19, R20, R21, R23, R24, R25, R27, R28, R29, R30, R31, R32, R33, R34, R37, R38, R40, R41, R42, R43, R47, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R59, R61, R62, R63, R64, R66, R67, R72, and R75) reviewed for room size in the sample of 61.Findings include:A Hall Rooms 1 - 12 are all Medicaid certified and provide 75 square feet per bed.B Hall Rooms 1 - 6 and 8 are all Medicaid certified and provide 75 square feet per Bed.C Hall Rooms 1 -8, 10 and 12 are all Medicaid certified and provide 75 square feet per bed.D Hall rooms [ROOM NUMBERS] are Medicaid certified and provide 77 square feet per bed.On 09/16/25 at 9:36 AM, V18 (Housekeeper) measured the rooms and verified that R1, R2, R3, R4, R5, R&, R8, R10, R11, R12, R14, R17, R18, R19, R20, R21, R23, R24, R25, R27, R28, R29, R30, R31, R32, R33, R34, R37, R38,…

    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 · No revisit needed
  • No harm found · Bcited before2024-06-14 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 and interview, the facility failed to provide 80 square feet of floor space per resident bed for 50 residents (R2, R3, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R21, R22, R23, R24, R26, R27, R28, R29, R32, R35, R37, R38, R41, R42, R45, R46, R47, R49, R51, R52, R53, R55, R58, R58, R59, R60, R61, R62, R63, R64, R167, R168, R169, R217, R267) reviewed for room size in the sample of 63. Findings include: A Hall Rooms 1 - 12 are all Medicaid certified and provide 75 square feet per bed. B Hall Rooms 1 - 6 and 8 are all Medicaid certified and provide 75 square feet per Bed. C Hall Rooms 1 -8, 10 and 12 are all Medicaid certified and provide 75 square feet per bed. D Hall rooms [ROOM NUMBERS] are Medicaid certified and provide 77 square feet per bed. On 06/14/24 at 11:00 AM, V17 (Maintenance Director) measured the rooms and verified that R2, R3, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R21, R22, R23, R24, R26, R27, R28, R29, R32, R35, R37, R38, R41, R42, R45,…

    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 · Waiver has been granted
  • No harm found · Bcited before2023-09-13 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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 and interview, the facility failed to provide 80 square feet of floor space per resident bed for 54 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, R16, R17,R18, R19, R20, R22, R23, R25, R26, R27, R28, R30, R31,R33, R34, R35, R36, R37, R38, R39, R40, R41, R42,R45, R44, R46, R47, R48, R49, R51, R52, R54, R55, R56,R57, R110, R160, R210, R260, R261) reviewed for room size in the sample of 54. Findings Include: On 9/7/2023 at 8:39 AM, V1 (Administrator) stated there have been no changes to the historical measurements and accuracy of the facility's waivered resident room numbers and certifications. V1 stated: - A Hall Rooms 1 - 12 are all Medicaid certified and provide 75 square feet per bed - B Hall Rooms 1 - 6 and 8 are all Medicare certified and provide 75 square feet per bed - C Hall Rooms 1 -8, 10 and 12 are all Medicaid certified and provide 75 square feet per bed - D Hall rooms [ROOM NUMBERS] are Medicaid certified and provide 77 square feet per bed On 9/13/2023 at…

    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 · Waiver has been granted

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to WLC MANAGEMENT FIRM — 18 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 52.8-0.8 vs chain
Health inspection 3 of 53.7-0.7 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 2 of 51.5+0.5 vs chain
The other 17 homes this chain runs (chain average 2.8★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
STOUT, SCOTTIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 06/01/2023
WLC MANAGEMENT FIRM LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/03/2025

CMS files one row per role, so the 4 rows in the source record cover these 2 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.

1 organizational owner 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.

$3.2M
Net patient revenuemost recent cost report
+19.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 65%Medicare 5%Other / private 30%

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

$180per resident / day
operating cost
$5,468per month
≈ monthly operating cost
$222per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

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

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145497. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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