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Prairie Manor Nrsg & Rehab Ctr

345 Dixie Highway, Chicago Heights, IL 60411 · For profit - Limited Liability company · 148 certified beds · (708) 754-7601 Medicare & Medicaid certified

Call the home — (708) 754-7601 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 20235 actual-harm citations
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 5 actual-harm citations
  • a high number of inspection citations overall (30) — 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)
  • about 21% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
333 Dixie Hwy · (708) 679-2063 · Call to confirm hours
Pharmacy
650 Dixie Hwy · (708) 755-0058 · Call to confirm hours
Grocery
200 Dixie Hwy · (708) 898-2204 · Call to confirm hours
Park
10 Holbrook Rd · (708) 755-1351 · Typically dawn to dusk

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 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 improved from 2 to 4 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 rating4★
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 increased4.4%13.4%15.4%better
Long-stay residents who lose too much weight4.8%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.7%1.5%2.0%better
Long-stay residents with depressive symptoms100.0%54.2%6.5%worse 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 injury1.5%3.1%3.3%better
Long-stay residents whose ability to walk worsened6.4%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.7%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine74.0%91.8%95.3%worse
Long-stay residents with pressure ulcers3.9%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control17.5%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table13.4%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.7%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine15.5%63.1%79.4%worse
Short-stay residents rehospitalized after admission19.6%26.1%22.6%better
Short-stay residents with an outpatient ER visit2.9%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days0.742.021.67better
Long-stay outpatient ER visits per 1,000 resident days1.632.221.80typical

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.

53.0% 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 140 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.0%U.S. median 51.5%
Got home and stayed home
11.7%U.S. median 10.7%
Went back to hospital
54.1%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 54.1% 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 61 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 0.23 therapist hours per resident per day in 2026Q1 — more than 30% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 49% 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 SNF53.0%CMS range 44.4–61.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.7%CMS range 8.6–15.110.7%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 discharge54.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge55.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge49.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were 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 discharge96.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened6.0%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 hospitalization7.8%CMS range 4.5–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.291.02Oct 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

0.44
RN hours/ resident / day
0.90
LPN hours/ resident / day
1.92
Aide hours/ resident / day
3.26
Total nurse hours/ resident / day
0.33
RN hoursweekends
39.7%
Total nursing turnover
35.7%
RN turnover

How full it usually is: this home is certified for 148 beds and averages 130.0 residents a day — about 88% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.26 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.92 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 2.91 hrs/resident/day on weekends vs 3.41 on weekdays — 15% thinner on weekends. RN hours go from 0.49 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

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

Inspection trend

2
deficiencies at the latest standard inspection (2024-07-12)
9
at the previous standard inspection (2023-08-04)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

30 citations, most serious first. The 15 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2024-09-12 · 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 adequately supervise residents assessed as being at risk for falls and in the dementia unit, failed to make sure that fall interventions were implemented for 2 residents (R2 and R3) and failed to have any base line fall intervention/ adequate supervision for a newly admitted resident with history of falls (R1). These failures affected three (R1, R2 and R3) of five residents reviewed for falls/injury. These failures resulted in R1 having a fall in the dining that resulted in a right femur fracture, requiring surgery; R2 had a fall in her room and sustained a femur fracture requiring a surgical procedure; and R3 had a fall in her room and sustained a right distal clavicle fracture, which required treatment at a local hospital. Findings include: 1. R1 is [AGE] years old admitted to the facility on [DATE], past medical history includes, but not limited to other specified sepsis, fracture of unspecified part of neck of right femur subsequent…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-08-22 · 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 interviews and records reviewed the facility failed to prevent an incident of resident-to-resident physical assault. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 attacking R1 unprovoked with a belt to R1's leg. R1 being a severely cognitive resident it is reasonable to conclude this resulted in R1 suffering psychological feelings of fear after being attacked by R2. The Findings include: R1 has diagnosis including but not limited to Dementia, Major Depressive Disorder, Alzheimer's Disease, Generalized Anxiety Disorder, and Weakness. R1's cognitive assessment dated [DATE] is a 6, severely impaired. R2 has diagnosis including but not limited to Unspecified Dementia and Alzheimer's Disease. R2's cognitive assessment dated [DATE] is a 0, severely impaired. On 8/15/23 at 10:49AM R1 observed in the dining room but did not provide statement. On 8/15/23 at 11:28AM V1, Licensed Practical Nurse (LPN), said during the night shift in the morning hours, V7,…

    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 before2022-08-25 · 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 observations, interviews, and record reviews, the facility failed to honor the residents' right to choose to be a resident of the facility by not honoring the residents' request to return home after completion of rehabilitation therapy. This failure applied to one of one (R93) resident reviewed for resident rights and has resulted in R93 suffering extreme stress and feeling symptoms of depression due to not being able to discharge from the facility. Findings include: R93 is an [AGE] year-old female admitted into the facility on [DATE] with the diagnosis of but not limited to benign neoplasm of meninges, late on set of Dementia history of UTI Urinary tract infection, Hallucinations and Hard of Hearing. On 08/22/2022 surveyor observed R93 sitting up in her chair making phone calls. R93 was able to communicate to the surveyor and make needs and concerns known. R93 has a hearing deficit and when communicating with R93 you must speak directly in her ear. On 08/22/2022 at 12:00pm during resident interview,…

    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 before2022-08-25 · 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 observations, interviews, and record reviews, the facility failed to keep a resident free from mental abuse by not providing the resident with an explanation of why the facility is requesting a court appointed guardian for the resident. This failure applied to one of one (R93) resident reviewed for mental abuse and has resulted in R93 suffering extreme stress and feeling symptoms of depression due to not being able to discharge from the facility. Findings include: R93 is an [AGE] year old female admitted into the facility on [DATE] with the diagnosis of but not limited to benign neoplasm of meninges, late on set of Dementia history of UTI Urinary tract infection, Hallucinations and Hard of Hearing. On 08/22/2022 surveyor observed R93 sitting up in her chair making phone calls. R93 was able to communicate to the surveyor and make needs and concerns known. R93 has a hearing deficit and when communicating with R93 you have to speak directly in her ear. On 08/22/2022 at 12:00pm during resident interview,…

    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 · G2022-08-25 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 observations, interviews, and record reviews, the facility failed to follow their policy by not completing a comprehensive assessment after a resident's change in medical condition and when adding new diagnoses' to residents' plan of care. This failure applied to one of one (R93) residents reviewed for comprehensive assessment and has resulted in R93 being deemed unfit to make decisions without thorough documentation that the physician verified or reconsider underlying causes of cognitive impairment (including recent urinary tract infection, known to cause delirium) and/or failing to include diagnostic tests and collaboration with other physician specialists (such as neurology) when giving the resident a new diagnosis of dementia. Findings include: R93 is an [AGE] year old female admitted into the facility on [DATE] with the diagnosis of but not limited to benign neoplasm of meninges, late on set of Dementia history of UTI Urinary tract infection, Hallucinations and Hard of Hearing. On 08/22/2022…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to follow its enhanced barrier precautions (EBP) policy and don appropriate PPE (personal protective equipment) prior to entering an EBP resident room to provide direct resident care and failed to perform hand hygiene before exiting a resident's room after providing direct resident care. These failures affected four residents (R2, R3, R4, and R5) out of five residents reviewed for infection control in a sample of 6. Findings include: On 12/18/25 at 11:04 AM, V10 CNA (certified nurse aide) was observed entering R3's EBP room and rearranging R3's personal items on bedside table. V10 then exited R3's room with R3's water pitcher and placed it on the counter at the nurses' station. V10 was then observed placing the mechanical lift device in the tub room and return to the nurses' station to wash hands. V10 then filled R3's water pitcher and brought into R3's room. On 12/18/25 at 11:25 AM, V6 CNA entered R2's EBP room to provide incontinence care. V6 did not don a gown prior to entering R2's room. At 11:31 AM, V6…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to have the low air loss mattress at the correct weight setting for one resident (R2) with a stage 4 pressure ulcer, who is at risk for skin breakdown and requires extensive assistance with turning/repositioning, out of three residents reviewed for wound management in a sample of 6. Findings include:On 12/19/25 at 8:55 AM, this surveyor observed V3 (wound care nurse) provide wound care treatment for R2's sacral pressure ulcer. R2 was observed to have a low air loss mattress with the weight setting at 400 pounds. On 12/19/25 at 9:05 AM, V3 stated that the weight on R2's low air loss mattress is locked and V3 does not know how to unlock it to adjust the weight setting. V3 stated that the machine is set for a person weighing 400 pounds. V3 stated that she knows R2 does not weigh 400 pounds but would have to check R2's medical record to know what R2's current weight is. V3 stated that the weight setting on the mattress should be checked daily. V3 stated that she will have to ask maintenance to come fix the weight…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement effective fall interventions related to the root cause of a resident with multiple falls. This affected one of three residents (R1) reviewed for falls. This failure resulted in R1 having six falls in six months with no change in fall interventions. Findings Include: R1 is an [AGE] year old with the following diagnosis: Parkinson's disease, functional quadriplegia, difficulty in walking, and orthostatic hypotension. A Plan of Care note dated [DATE] documents the nurse was called to R1's room by another staff member. The nurse observed R1 on the floor sitting in front of the wheelchair. R1 was assisted back to the wheelchair. The Care Plan dated [DATE] documents R1 is a high fall risk related to diagnosis of Parkinsonism, weakness, syncope, depression, and coronary artery disease. Interventions were added after each fall. The following interventions were documented on [DATE]: anticipate and meet R1's needs, follow facility fall…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess and monitor for pressure ulcers for a resident who is at high risk for pressure ulcers. This deficiency affects one (R2) of three residents reviewed for Pressure Ulcer Prevention Program. Findings include: On 2/13/25 at 11:25 AM, V4 (Wound Care Nurse) said that R2 was sent to the hospital on 1/24/25 for change in condition, R2 was observed unresponsive and abnormal vital signs. V4 said R2 only had scar tissue to the sacral area but no open skin. When R2 returned to the facility on 1/31/25, R2 returned with an unstageable wound that the hospital did debridement. V4 said that R2's son and husband were made aware of resident change of condition and hospital transfer. V4 said that R2's wound care is done weekly, and measurements are also done on a weekly basis and weekly wound rounds with MD. On 2/13/25 at 1:45PM, V2 (Director of Nursing) said that weekly skin assessments are completed during wound care treatments and are documented on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-07-12 · 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 monitor and record daily freezer and refrigerator temperatures for food safety. This deficiency may potentially affect all 123 residents receiving food from the facility. Findings include: On 7/9/2024 at 10:02AM, Rounds made to kitchen with V5 Dietary Manager (DM). Observed Freezer and Cooler/Refrigerator temperature were not monitored today. V5 said that the cook should monitor and record the temperature today at 5am. It was not done because they were short this morning. V5 read the current temperature of freezer at -3F (Fahrenheit) and Cooler/Refrigerator at 32F. Daily Freezer/Refrigerator temperature log July 2024. No temperature recording made for 7/9/24. Instruction: This log will be maintained for each refrigerator and freezer (both walk in and reach in units) in the facility. A designated food service employee will record the time, air temperature and their initials. The food service supervisor for each facility will verify that the food service employees have taken the required temperatures by visually…

    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 · Dcited before2024-07-12 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure coordinated care was implemented by failure to document hospice services rendered to resident's medical record that is available and accessible to interdisciplinary team (IDT). This deficiency affects two (R22 and R45) of three residents in the sample of 25 reviewed for Hospice care Management. Findings include: On 7/9/2024 at 11:00AM, V8 LPN (Licensed Practical Nurse) and V9 LPN said that R22 and R45 are both on hospice care. V9 showed the hospice binder/charts for both residents. Reviewed both hospice binder charts with V9. Noted no documents found for R22. The folder is empty, only visits log from 6/12/24 to 7/4/24. No IDT progress notes found. Noted R45 hospice documents in binder but missing IDT progress notes. Noted R45's hospice visit log from 6/10/24 to 7/9/24. V9 said usually when hospice care staff comes to visit hospice resident, they document in the hospice binder. V9 said that usually Social Services coordinate 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to supervise and monitor a resident with a history of aggression and agitation to prevent a resident to resident assault. This affected 2 of 3 (R2, R1) resident reviewed for supervison. This failure resulted in R2 wandering into R1's room and physically assaulting R1 with a belt. The Findings include: R1 has diagnosis including but not limited to Dementia, Major Depressive Disorder, Alzheimer's Disease, Generalized Anxiety Disorder, and Weakness. R1's cognitive assessment dated [DATE] is a 6, severely impaired. R2 has diagnosis including but not limited to Unspecified Dementia and Alzheimer's Disease. R2's cognitive assessment dated [DATE] is a 0, severely impaired On 8/15/23 at 10:49AM R1 observed in the dining but did not provide statement. On 8/15/23 at 11:28AM V1, Licensed Practical Nurse (LPN), said V7, Certified Nursing Assistant (CNA), called me I was passing medications. V1 said R2 was in the room of another patient. V1 said R2 was agitated. 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 · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-04 · 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 — the official record, unedited, may be distressing

    Based on observation, interview and record review the facility failed to maintain dignity and respect during dining observation for one of one resident (R99) reviewed for resident rights in a sample of 25. Findings include: On 8/1/2023 at 12:15pm V20 (Certified Nursing Assistant-CNA) was observed standing over R99 assisting with feeding a meal. On 8/1/2023 at 12:18pm V20 said we don't have any chairs in this dining room, yes, I should be sitting down while assisting with meals. On 8/1/2023 at 2:30pm V3 (Director of Nursing-DON) said I expect all staff to respect the residents and have a seat while assisting with meals. A Care-plan dated 10/31/2022 R99 requires a mechanical soft diet. Facility Policy: Resident Rights Protocol for all Nursing Procedures 1. Prior to having direct-care responsibilities for residents, staff have appropriate in-service training on resident rights including: a. Resident dignity and respect:

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-04 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one (R70) out of seven residents reviewed for accommodation of needs in a sample of 25. Findings Include: On 08/02/23 at 11:15 AM, R70 was observed sitting in her wheelchair. Her call light was on the floor and not within her reach. On 8/2/2023 at 11:20 AM, V24 (CNA) observed that R70 call light was on the floor and not within the reach of R70. V24 said that the call light should be within R70's reach. On 8/2/2023 at 11:22 AM, V16 (Licensed Practical Nurse) said that call light should be within R70 reach. On 8/3/2023 at 12:00 PM, V3 (Director of Nursing) said that the call light within the resident's reach. R70 is an 86 years female admitted on [DATE] with diagnosis not limited to acute or chronic diastolic (congestive) heart failure, difficulty in walking, major depressive disorder, and acute kidney failure. R70 care plan dated 6/20/2022 documents: Keep call light in reach at all times.…

    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 · D2023-08-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop individualized comprehensive care plan to resident to meet his medical, nursing, and physiological needs in the facility. This deficiency affects one (R232) of three residents in the sample of 25 reviewed for Resident's comprehensive care plan. Findings include: On 8/1/23 at 10:50am, V15 LPN and V16 LPN said that R232's has indwelling catheter, biliary drainage, and on contact isolation for Clostridium difficile (C. Diff) infection. Observed R232's lying in bed. On 8/2/23 at 12:33pm, Review R232's medical record with V5 MDS (Minimum Data Set)/Care plan Coordinator. R232 is admitted on [DATE] with diagnosis listed in part but not limited to Calculus of gallbladder status post cholecystectomy, Urinary retention, Diabetes Mellitus type 2, Clostridium Difficile colitis. Physician order sheet indicated: Insulin lispro 4 units subcutaneous with meals four times a day to manage blood glucose. Heparin solution 5,000 units subcutaneous three…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · D2023-08-04 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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 follow its policy on medication safety by finding medications without physician order at resident's bedside. This deficiency affects one (65) of three residents in the sample of 25 reviewed for Resident's safety. Finding include: On 8/1/23 at 12:38pm, Observed R65 lying in bed. Observed the following medications at R65's bedside tray table in front of him namely: Diaper rash ointment (Desitin cream), Zinc oxide ointment, hemorrhoidal ointment, Hydrocortisone cream ([NAME] eczema cream), Neuropathy cream, and Diaper rash cream (Riley's butt cream) labeled for another resident's name. R65 said that these are all his medications, and he is using it. He said that his daughter brought these medications several weeks ago and applied when she comes to visit. Called V16 LPN to R65's room and showed the medications at bedside tray table. V16 said that medications probably brought by his family. V16 said that R65 should not have medications 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review the facility failed to monitor the low air loss mattress is functioning properly on a resident who has multiple stage 4 and unstageable of pressure ulcers. The facility also failed to follow the manufacturer recommendation of avoiding multiple layers of linens over the Low Air Loss mattress. This deficiency affects one (R122) of three residents in the sample of 25 reviewed for Pressure ulcer Management. Findings include: R122 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Metabolic Encephalopathy. Physician order sheet indicated: Pressure reducing mattress continuous. Care plan indicated: R122 has pressure ulcers noted at re-admission, and is at risk for slow, no healing of wound and further breakdown related to immobility, CVA (cerebrovascular accident) with left hemi, Diabetes, Anemia, Chronic Kidney disease and Protein calorie malnutrition.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-04 · 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 complete smoking assessment of resident upon admission who has history of conviction of arson. This deficiency affects one (R87) of three resident reviewed for Smoking Safety management. Findings include: On 8/1/23 at 11:00am V15 LPN and V16 LPN said that R87 is a smoker. On 8/1/23 at 1:22pm, Observed R87 propelling himself in the 1st floor unit. He said that he smokes without supervision. On 8/3/23 at 11:36am, Review R87's medical records with V11 Director of Social Services. R87 is admitted on [DATE]. Care plan indicated that he is identified offender. He was convicted of Arson in 1983 and retailed theft in 1987. Resident was assessed to be at risk for aggression based on this facility's aggression assessment. V11 said that she did not complete R87's smoking assessment upon admission. She completed it only when requested for it on 8/1/23. She said it was not done because she was on vacation when R87 was admitted . Facility's policy on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, interview, and record review the facility failed to secure catheter tubing for one resident (R40) of three residents reviewed for catheters in the sample of 25. Findings include: On 8/1/23 at 1:16 PM R40's indwelling urinary catheter was draining clear violet colored urine in the tubing. The urine in the collection bag was dark and brownish tinted. The catheter tubing is not secured to the resident's leg or body. On 8/1/23 at 1:20 PM V5 (Registered Nurse) said the catheter should be attached. On 8/1/23 at 1:50 PM V25 (Licensed Practical Nurse) said the catheter should be attached. She could pull on it. R40's wound care notes indicate that she has a Stage IV pressure ulcer on the sacrum. R40's Care Plan indicates that she requires indwelling (urinary) catheter R/T (related to) sacral wound. Policy: (Urinary) Catheter Insertion, Female Resident Revised August 2008 Steps in the Procedure 21. Attach catheter to drainage tubing. Tape catheter to inner thigh or secure with leg band. Secure drainage tubing to bottom bed sheet with clip from drainage set.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-04 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to follow its policy by failure to obtain physician order prior to provide hospice care services and resident's hospice medical records available and accessible to all interdisciplinary staff. This deficiency affects one (R108) of three resident in the sample of 25 reviewed for Hospice Care Services. Findings include: On 8/1/23 at 11:00am, V15 LPN and V16 LPN said that R108 is on hospice care services. V16 said the hospice binder or folder usually by the nursing station but she cannot find it. Observed R108 lying in bed with oxygen via nasal cannula. On 8/1/23 at 12:48pm, V16 LPN provided R108's hospice folder which includes admission orders dated 7/26/23, Interdisciplinary (IDT) Plan of care revision/Physician orders dated 7/27/23, Interdisciplinary Care plan/initial general POC (Plan of care) dated 7/26/23 and IDT visit logs dated 7/27/23, 7/28/23 and 7/31/23. No documentation included of what hospice services has provided to R108. On 8/1/23 at 1:03pm, Showed to V3 DON R108's hospice medical records. V3 said she…

    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 · Dcited before2023-08-04 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to perform hand washing after taking care of resident who is on isolation for clostridium difficile (C. Diff) infection. This deficiency affects one ( R232) of three residents in the sample of 25 reviewed for Infection control protocol. Findings include: On 8/1/23 at 11:30am, V10 Director of Rehab Services (DRS) observed donning PPE (Personal Protective Equipment) prior entering R232's room. V10 said that R232 is on contact isolation for C. diff. V10 said that she will provide therapy at bedside- toileting transfer. At 11:50am, Observed V10 DRS removed his PPE without performing hand washing and exited the room. V10 sanitized her hands using the alcohol-based hand rubs (ABHR) by the hallway. Informed V10 of observation made that she did not perform hand hygiene after removing the PPE and exiting R232's room. V10 said that she usually does not wash her hands inside the resident's room. V10 said she washed her hands at the nursing station. On 8/1/23 at 12:25pm Informed V3 DON of above observation. V3 said that after…

    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 before2022-08-25 · 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 observations, interviews, and record reviews, the facility failed to follow their policies and procedures for preparing food under sanitary conditions and infection control by not properly wearing masks, not properly wearing hairnets, not performing hand hygiene when indicated, not keeping outside items from the kitchen area, not storing food used for meal prep appropriately, not ensuring ice equipment is thoroughly clean, and not covering waste disposal bin when not in use. This failure has the potential to affect all 110 residents who currently reside in the facility. Findings include: 08/22/22 09:55 AM - 10:10AM Observed V32 (Prep Cook) walking through the kitchen with her mask worn underneath her nose and without a hairnet. Observed V32 placed on her hairnet and continued moving empty food carts without performing hand hygiene. Observed V34 (Dietary Aide) walking through the kitchen with her mask worn underneath her nose. Observed V34 hair exposed from underneath her hairnet. Observed V34 adjust her hairnet with gloved hands and continue preparing cutlery without…

    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 · Fcited before2022-08-25 · 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 observation, interview and record review the facility failed to follow standard precautions and prevent the spread of COVID-19 by 1.) failing to properly wear PPE (Personal Protective Equipment) in resident care areas; 2.) failing to isolate confirmed COVID-19 cases; 3.) failing to prevent symptomatic staff from being on duty; 4.) failing to screen employees and residents upon entrance to the facility; 5.) failing to follow standard hand hygiene protocols. These failures affect all 110 residents residing in the facility and has contributed to an active outbreak of COVID-19. Findings include: No screening was observed to be conducted upon entrance by visitors at any time during this survey. Staff were noted filling out a self-screening form, which was not reviewed by the receptionist. No temperatures were observed to be taken during the course of this survey. On 8/22/22, V1 (Administrator) displayed some signs of illness as noted by her statements in feeling warm, nasally, and with voice changes. On 8/24/22 at approximately 4:45PM, V1 was noted to have increased signs of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-08-25 · tag F0885 — failed to notify residents/families about COVID-19 — widespread
    Report COVID19 data to residents and families.
    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 report active COVID-19 cases to resident's family members or representatives and failed to report their current COVID-19 outbreak status to the local health department. These failures have the potential to affect all 110 residents residing in the facility at the time of this survey. Findings include: Observation 8/22/22; upon entering the facility, it was noted that a sign dated 8/16/22 was taped to the automatic sliding doors obstructed at the time of entrance. On 8/22/22 at the start of survey, it was noted that eight residents on the second floor were identified as being positive for COVID-19. On 8/23/22, three additional residents tested positive for COVID-19. On 8/24/22 at 2:30PM, V2 Director of Nursing said, the administrative staff calls the resident family members, and I don't know if that is documented anywhere in the health record. We have the sign posted at the door of entry to inform everyone coming in of the positive covid cases, but I see that we will have to move it. On 08/25/22 at 04:03 PM V22…

    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 · F2022-08-25 · tag F0886 — failed to test for COVID-19 as required — widespread
    Perform COVID19 testing on residents and staff.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their policies and procedures for facility-wide COVID-19 testing. This failure has the potential to affect all 110 residents currently residing in the facility at the time of this survey. Findings include: Facility line list of COVID-19 reviewed. On 8/22/22 the facility identified eight residents on the 2nd floor to have active COVID-19 infection. On 8/23/22, three additional residents tested positive for COVID-19. At this time, the facility did not institute facility wide testing per their written policy as presented. On 8/23/22 at 10:20AM, V3 LPN said, three more residents tested positive on the unit this morning for COVID. I was not tested today. On 8/24/22 at 2:30PM V2 DON (Director of Nursing) said, with this current outbreak, we are only testing Unit based. I directed the Unit manager to test the 2nd floor staff with the rapid tests. I have to find out if it was completed. Only unvaccinated staff were tested yesterday. We did not test anyone else in the building unless they were unvaccinated. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-08-25 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a physician's order for self-administration of medication for one (R72) of nine residents reviewed during medication administration and the facility failed to properly document that narcotic count was completed each shift per facility policy. These failures have the potential to affect 75 residents on the 1st and 3rd floor reviewed during medication storage and labeling observation. Findings include: On 08/23/22 at 10:46 AM the 3rd Floor Medication Cart was reviewed with V7 ADON Assistant Director of Nursing. The controlled substance check form for the 3rd floor medication cart #1 was observed to be incomplete. There are numerous blank unsigned areas noted on the document. V7 ADON was inquired. V7 ADON stated, I forgot to sign it this morning myself. It's the end of the shift checks for narcotics to make sure the count is good. There are a lot of holes. Review of the 1st floor medication cart at 11:30 AM with V10 LPN Licensed…

    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 · E2022-08-25 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow their protocol of labeling medication with open date; failed to discard expired insulin vials; and failed to ensure that inhalers were labeled with the residents name and medication open date. This failure applied to eight of eight (R7, R8, R12, R50, R66, R72, R88, and R91) residents reviewed for medication storage. Findings include: On 08/23/22 at 10:25 AM, the 3rd Floor Medication Cart Review was conducted with V7 ADON Assistant Director of Nursing. 1. Resident # 72 Lantus Insulin Glargine 100 units/ml (milliliters), inject 10 units subcutaneous at bedtime. The insulin vial is dated open 6/2/22 and expires 6/29/22. The vial is open in top drawer of the medication cart. V7 ADON was inquired of the insulin. V7 ADON stated, It's expired, this one should be tossed. 2. Resident # 72 Novolog insulin aspart 100 units/ml (milliliters), inject 2 units subcutaneous three times a day before meals. The insulin vial is dated open 6/29/22 and expires 7/26/22. The vial is open in top drawer of the medication cart.…

    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 · D2022-08-25 · 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 observation, interview, and record review, the facility failed to report and investigate an injury of unknown origin for potential abuse due to staff not immediately reporting a new forehead injury to the abuse coordinator. This failure applied to one (R62) of one resident reviewed for abuse. Findings include: R62 is an [AGE] year old male admitted to the facility 11/26/21 with diagnoses that include; dementia, cognitive communication deficit and weakness. R62 alert but not oriented with a BIMS of 02 and is able to walk independently with supervision. On 8/22/22 at 11:20AM, R62 was noted walking in the hall and being re-directed by V21 Activity Director. R62 had an abrasion on his right forehead, red in color. Review of facility presented documents and R62's medical record, do not include documentation of any accident or incident related to observed forehead injury. On 8/24/22 at 1:11PM, R62 was noted alert and walking in the hall. R62 had a dark, blackish bruise, with an abrasion on the right forehead.…

    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 · D2022-08-25 · 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 observation, interview, and record review, the facility failed to follow their care protocols by not providing nail care to residents who require assistance with ADLs (activities of daily living). This failure applied to two (R67 and R113) of two residents reviewed for assistance with ADLs in a sample of 47 residents. Findings include: R113 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Chronic Kidney Disease, Bradycardia, Myalgia, and Unspecified injury of wright wrist, hand and fingers. According to MDS (Minimum Data Set) dated 06/08/2022 under section G, R113 requires 2+ extensive assist in completing her personal hygiene. On 08/22/22 at 11:03 AM Upon initial observation, surveyor noted R113's fingernails to be untrimmed and dirty. R113 indicated that she doesn't remember when was the last time staff trimmed her fingernails. On 08/23/22 at 09:58 AM Upon observation, surveyor noted R113's fingernails to be untrimmed and dirty. On 08/23/2022 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-08-25 · 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 observations, interviews, and record reviews, the facility failed to notify the registered dietitian of a change in food intake and failed to follow their interventions and treatments for weight loss prevention for a resident with a history of weight loss and poor oral intake. This failure applied to one (R46) of one resident reviewed for nutrition in a total sample of 33 residents. Findings include: On 08/23/22 at 10:23 AM R46 stated she has lost weight and has not been eating as well. R46 stated she is not a big eater. R46 stated no one has talked with her about her weight, eating habits, or preferences. R46 stated she receives a protein drink not even once a day. R46 stated she believes she was supposed to receive a protein supplement once daily but that has stopped and she is not sure why. R46 stated her favorite meal is breakfast. R46 stated she doesn't like spinach and they serve it a couple of times a week so she just doesn't eat it. On 08/23/22 at 12:39 PM V37 (Certified Nursing Assistant)…

    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

“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.

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 EXTENDED CARE CLINICAL — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 52.2+1.8 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 1 of 51.1-0.1 vs chain
Quality measures 5 of 53.6+1.4 vs chain
The other 8 homes this chain runs (chain average 2.2★, 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 / managerTypeRoleShareSince
ADAMS VALES ACCUMULATION TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF11%since 01/01/2013
DANIEL ROTHNER ACCUMULATION TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF11%since 01/23/2025
KATHRYN VALES ACCUMULATION TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF11%since 01/01/2013
KIMBERLY VALES ACCUMULATION TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF11%since 01/01/2013
MELISSA ROTHNER ACCUMULATION TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF11%since 01/01/2013
NATHAN AND SHIRLEY ROTHNER FAMILY TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF22%since 01/01/2013
RACHEL ROTHNER ACCUMULATION TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF11%since 01/01/2013
WILLIAM ROTHNER ACCUMULATION TRUSTOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNF11%since 01/01/2013
ARONIN, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2013
ISRAEL, LEVIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2013
JOSHI, SANJEEVIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2013
STUCKER, MARYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2013
ROTHNER, DANIELIndividualTRUSTEE OF THE SNFsince 01/01/2013
ROTHNER, MELISSAIndividualTRUSTEE OF THE SNFsince 01/01/2013
ROTHNER, RACHELIndividualTRUSTEE OF THE SNFsince 01/01/2013
ROTHNER, WILLIAMIndividualTRUSTEE OF THE SNFsince 01/01/2013
RUDOLPH, KIMBERLYIndividualTRUSTEE OF THE SNFsince 01/01/2013
VALES, ADAMIndividualTRUSTEE OF THE SNFsince 01/01/2013
VALES, KATHRYNIndividualTRUSTEE OF THE SNFsince 01/01/2013
EXTENDED CARE CLINICAL LLCOrganizationADP OF THE SNFsince 01/01/2013
EXTENDED CARE CONSULTING LLCOrganizationADP OF THE SNFsince 01/01/2013

CMS files one row per role, so the 38 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted.

10 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.

$15.0M
Net patient revenuemost recent cost report
-7.3%
Operating marginrevenue minus expenses
$3.3M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 13%Other / private 12%

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

$347per resident / day
operating cost
$10,554per month
≈ monthly operating cost
$324per 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 145629. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-12, 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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