Fargo Health Care Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.06 therapist hours per resident per day in 2026Q1 — more than 2% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 99 beds and averages 93.3 residents a day — about 94% occupied, or roughly 6 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 2.83 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 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 2.52 hrs/resident/day on weekends vs 2.95 on weekdays — 15% thinner on weekends. RN hours go from 0.58 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 20% is below 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

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.

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.

42 citations, most serious first. The 18 most serious are shown; the remaining 24 are one tap away and print in full.

• Actual harm · Gcited before2026-03-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to ensure that a resident (R2) remains free from verbal and physical abuse/assault and free from injury (fracture) from another resident (R3) and failed to follow their abuse policy. These failures caused physical harm to R2, having a fracture and the need for emergency treatment and surgical intervention (sutures). These failures affected one resident (R2) out of three residents reviewed for verbal and physical abuse/assault.Findings include:Facility's Reported Final Incident Investigation Report (1/29/2026), showed in part that on 1/26/2026 approximately around 3:45 PM, verbal altercation occurred between R2 and R3 over a cigarette lighter when returning from independent pass and standing on the facility's smoking patio. Verbal altercation and name calling occurred between the two residents and R3 became agitated and hit R2 on the right cheek area, which resulted from R2's bleeding and needing emergency care treatment. R2 returned from hospital with diagnosis of closed fracture of right maxillary sinus and R3 was…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-11-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents environment was free from accident hazards. This failure affected 2 (R1 and R9) residents reviewed for accident hazards in the total sample of 9 residents. This failure resulted in R1 having access to scissors and used the scissors to cut her wrist and received 2 stitches as treatment. Findings include: 1. R1's ([DATE]) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R1's mental status as cognitively intact. R1's ([DATE]) Standing Order documented, in part Resident may have independent pass privileges. R1's census list documented that R1 was admitted at the facility on [DATE], was sent out to a hospital on [DATE] and readmitted on [DATE]. R1's ([DATE]) Resident Inventory Record did not include scissors. R1's ([DATE]) Accident/Incident documented, in part at 2:35am resident pulled call light, staff responded and entered the room, asked what…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to ensure that one resident (R2) was free from abuse from her roommate (R3). This failure resulted in R2 being struck by R3 and sustaining a broken nose. Findings include: R2 is an [AGE] year old with diagnosis including but not limited to: unspecified dementia, unspecified severe protein-calorie malnutrition, age - related osteoporosis without chronic pathological fracture, chronic pain and cognitive communication deficit. R3 is a [AGE] year old with diagnosis including but not limited to: bipolar disorder, generalized anxiety disorder, major depressive disorder, type 2 diabetes mellitus, restlessness and agitation. R7 is a [AGE] year old with diagnosis including but not limited to: essential hypertension, chronic obstructive pulmonary disease with acute exacerbation, pain in left leg, major depressive disorder and anxiety disorder. R7 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident (R3) was free from physical abuse. This failure resulted in R3 sustaining a bruise and skin tear to the left arm that required a dressing twice a day and R3 being afraid at the facility. Findings include: The facility's Preliminary Incident Investigation Report to the local state agency dated 11/22/24 completed by V1 (Administrator) shows a report of physical abuse with alleged individual V11 (CNA/Certified Nursing Assistant) and R3. The facility's Completed Incident Investigation Report to the local state agency dated 11/27/24 competed by V1 documents, in part On 11/24/24 (should be 11/22/24) at approximately 11:45 am, R3's CNA (V14) was making rounds. V14 stated, I (V14) saw bleeding on the left arm. I (V14) asked what happen and R3 said the night CNA did that to me. Based on the known facts, medical record review, and interviews, the following conclusion have (sic) been determined about the allegation: Abuse-Neglect Founded.…

  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 before2024-09-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect the residents' right to be free from physical abuse for 3 (R5, R2, and R3) of 4 residents reviewed for abuse. These failures resulted in R5, getting hit on the top of the head by V9 (Certified Nurse Assistant/CNA), as well as R2 and R3 engaging in a verbal and physical altercation while unsupervised that resulted in injuries (scratch wounds). This failure resulted in R5, who is cognitively impaired, as a reasonable person that would not expect to be harmed in their own home or health care facility, causing them to feel fear, anxiety, and anger. Findings include: 1. R5 is [AGE] years old, initially admitted in the facility on 5/1/2018. R5's medical diagnosis includes hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, convulsion, schizophrenia, dementia, mood disturbance, and anxiety. R5 has a BIMS (Brief Interview of Mental Status) of 0 dated 6/3/2024 that means R5 rarely or never understood.…

  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 before2024-05-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a resident's fall from the bed to the floor, who was assessed as a two person assist for bed mobility. This failure affected 1 (R44) of 28 residents reviewed for falls. R44 was emergently transferred to the hospital with increased pain and experiences psychosocial harm, feeling scared and afraid while being turned in bed by staff. Findings include: On 5/20/24 at 11:13am, R44 stated that R44 has been in the facility for almost 2 years, and I (R44) don't walk. R44 stated, I fell out of bed about 2 months ago. I had moved to (another floor) because they needed my room as an isolation room. R44 stated that in R44's current room, R44's bed is up against the wall and that the room on the other floor (where R44 had been temporarily transferred on 2/13/24) didn't have a wall next to R44's bed, so R44's bed was open on both sides. R44 stated, (V20 Certified Nursing Assistant/CNA) was on the same (one) side and pushed me over to change me. I was holding…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and review of records, the facility failed to protect the residents' right to be free from physical abuse by resident (R2) against another resident (R1). The facility failed to follow their abuse policy by not having preventative measures in place for a resident with a history of physical, verbal, and sexually inappropriate behavior. The facility failed to have preventative measures in residents (R1) care plan before and after a resident (R1) was physically abused. These failures led to a resident (R2) physically assaulting another resident (R1) causing multiple injuries. Findings include: Facility reportable dated 8/1/2023 between R1 and R2: Per report facility substantiated the incident of physical abuse between R1 and R2 did occur, and that due to the incident R1 sustained injuries. Per hospital records dated 8/2/2023 R1 sustained multiple bruises to the right side of her face, under her right eye, right upper arm and forearm, left shoulder, and scratches to her left forearm. R1 is [AGE]…

  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 before2023-08-10 · 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 ensure the resident receives adequate supervision and assistance devices to prevent accidents in 1 (R1) of three residents (R1, R3 and R4) included in the sample. This failure resulted in R1 sustaining a closed fracture of phalanx of right fourth toe with laceration requiring 3 sutures. Findings include: R1 is a [AGE] year-old male with a diagnosis including COPD, Schizophrenia, and Parkinson's Disease. R1 has a Brief Interview for Mental Status of 11/15. R1 requires 1-person physical assistance for transfer and walking in room. R1 uses a wheelchair to ambulate. R1 wanders and has an electric monitoring device on ankle to help prevent elopement. Incident report sent to Illinois Department of Public Health shows on 6/11/23 at 6:45AM resident accidentally ran over by staff with his wheelchair, resulting in R1 sustaining a laceration to his right 4th toe, first aid rendered. Resident transferred to hospital and returned the same day. Received…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-07 · 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 to ensure that an involuntary discharge was not based on the residents' condition at the time of transfer to acute care and failed to provide physician's documentation of the reasons a resident was involuntarily discharged from the facility in the resident's medical record. These deficient practices affected two of three residents (R1 and R4) reviewed for involuntary discharge. 1. R1 was admitted to the facility on [DATE] and was discharged to the hospital on 9/28/2025 and was not allowed to return to the facility. R1 was petitioned for involuntary discharge and was also served a 30-day notice for involuntary transfer and discharge. Progress notes dated 9/28/2025 2:39 a.m. document R1 stated am depressed because my sister died and want to go to the hospital. R1 also stated that R1 cut herself with scissors and was observed with bleeding on R1's right wrist. R1 was sent to the hospital via 911 and returned the same day with stitches to her right wrist, was…

  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 · D2026-02-07 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement care plan for psychosocial and mental well being and failed to provide the necessary services for the behavioral health needs of a resident. This applies to one (R1) of 4 residents reviewed for behaviors. As a result, R1 harmed self requiring psychiatric hospitalization. Findings include: According to the Electronic Health Record (EHR) R1 had diagnoses including Other seizures; Bipolar disorder, current episode depressed, Gastro-esophageal reflux disease without esophagitis; Unspecified asthma, Major depressive disorder, single episode, Other chronic pain; Restlessness and agitation; Hypo-osmolality and hyponatremia; Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, without status epilepticus; Pain in unspecified knee; Type 2 diabetes mellitus with other diabetic kidney complication; Cough, unspecified; and Tinea pedisR1 was admitted to the facility on [DATE] and was…

  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 before2025-08-29 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of records the facility failed to provide admission contract/agreement packets in a timely manner to 5 out of 5 residents (R1, R6, R7, R8 and R9). Findings include: R1 is [AGE] years old, initially admitted on [DATE]. R1 medical diagnosis includes hypertension, major depression (single episode), bipolar disorder, anxiety disorder. Per MDS assessment of R1 dated 06/20/2025, R1 has a BIMS (Brief Interview of Mental Status) score of 15 or cognition is intact. On 08/26/2025 at 10:12 AM, R1 stated that facility let him sign a contract for services recently. R1 presented a Resident admission Packet. R1 stated that it is a contract for services and terms and condition for resident to be in the facility. R1 stated that he dislikes the contract because there are blank areas and missing pages. R1 stated that facility did not give him enough time to review the contract. R1 stated that V1 (Administrator) called him to a meeting. In that meeting, V1 told him that he told other…

  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 · F2025-08-15 · tag F0803 — failed to meet residents' dietary needs — widespread
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the 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 follow menus, spreadsheets, and recipes. These failures have the potential to affect all 93 residents receiving food prepared in the facility's kitchen. Findings Include:On 08/12/2025 at 11:52 AM, R63 said, I don't get enough to eat and I'm always hungry. On 08/12/2025 at 12:22 PM, observed R63 eating lunch in unit dining room. R63 received ground turkey with gravy, sweet potato, peas, yellow cake, and juice. R63 did not received any bread or a substitution for bread.On 08/12/2025 at 12:30 PM, observed R7's lunch tray. R7 received turkey, sweet potatoes, peas, cake, nectar thick water and juice. R7 did not received any bread or substitution for bread.On 08/12/2025 at 12:45 PM, observed R21's lunch tray. R21 received pureed turkey, pureed sweet potatoes, pureed peas, pureed cake, and honey thickened water and juice. R21 did not receive pureed bread or substitution for pureed bread. On 08/13/25 at 11:47 AM, observed lunch tray line in…

  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 before2025-08-15 · 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 a.) ensure kitchen staff wearing appropriate hair covering; b.) food items were properly labeled and dated; c.) food items stored according to manufacturer's guidelines. These failures have the potential to affect all 93 residents receiving food prepared in the facility's kitchen. Findings include:On 08/12/25 at 9:13 AM, during initial kitchen tour observed V15 (Dietary Aide) by the food prep area. V15 had a beard and mustache and was not wearing any type of covering over his beard and mustache. On 08/12/25 at 9:16 AM, V14 (Dietary Manager) observed V15 and said that his beard and mustache should be covered with a hair net and that he should have put it on as soon as he entered the kitchen. V14 stated the kitchen has an adequate supply of beard protectors and then showed surveyor a plastic bag full of beard protectors by the kitchen front door, next to a bag of hairnets. V14 stated any facial hair an employee has should be covered with a beard protector. On 08/12/25 at 9:19 AM, V14 stated any opened food…

  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 before2025-08-15 · 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 observations, interviews, and record reviews, the facility failed to practice infection control and prevention measures to ensure staff wore appropriate personal protective equipment (PPE) for one (R5) resident on enhanced barrier precautions and appropriately handle and transport linen to prevent potential contamination. The facility also failed to track and register to report possible XDROs (Extensively Drug-Resistant Organisms) to the registry. These failures have the potential to affect all 93 residents residing in the facility.Findings include:On 8/12/2025 at 11:20 AM, surveyor did laundry service walk-through with V8 (Laundry Attendant). When asked about facility's laundry chute, V8 opened a door labeled 'Storage.' There was a large, gray bin filled with linen and resident clothing. Some of the linens and resident clothing were not contained in bags. When V8 opened the chute's door, multiple loose linen and resident clothing fell onto the bin. V8 stated staff are supposed to bag all linen and resident clothing but staff don't always do so. V8 also stated 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-15 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  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 ensure a medication error rate of less than 5% for 4 (R2, R34, R56, R60) of 4 residents with 9 errors for 30 medication administration opportunities. This resulted in a medication error rate of 30%. The findings include: On 8/12/2025 9:31 AM Medication administration observation conducted with V4 (Registered Nurse / RN). Observed V4 prepared and administered the following medications to R2: Xcopri 50mg 1 tabletLevetiracetam 750MG 1 tabletValproic acid 250mg/5ml oral solution 10MLAptiom 400mg 1 tabletSodium chloride 1 GRAM 1 tabletFluoxetine 20 MG Oral 1 CapsuleLamotrigine 25MG 1 tablet Loratadine 10mg 1 tablet Observed R2 took prepared medications by mouth.R2's POS (Physician Order Sheet and MAR (Medication Administration Record) showed order not limited: Levetiracetam 750mg 1 tablet by mouth twice a day scheduled at 8am and 4pm. Valproic acid 250mg/5ml oral solution give 10ml (500mg) by oral route 3 times per day scheduled at 8am, 1pm and 6pm. Lamotrigine 25mg give 1 tablet by oral route 2 times per day…

  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 · Ecited before2025-08-15 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to (a) properly date opened multi-dose inhaler for 2 (R18, R103) residents, (b) ensure that house stock medication (multidose Tubersol solution) was stored properly at appropriate temperature from 2 of 3 medication carts and 2 of 3 medication rooms inspected for medication storage and labeling. The findings include:On [DATE] at 10:13 AM 2nd floor medication cart inspected with V5 (LPN / LICENSED PRACTICAL NURSE) and found the following: Tubersol solution 1 vial kept in clear zip lock and showed house stock, pharmacy label indicated keep in refrigerator. Tubersol solution was found inside the medication cart not properly stored at appropriate temperature. R103's Trelegy ellipta 100mcg inhaler opened no date. 3 same inhalers were opened with no date. Pharmacy label indicated discard 42 days after opening. R18's Albuterol sulfate HFA 90mcg inhaler opened with no date.V5 said Tubersol solution is a House stock ordered from the pharmacy, not sure…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-15 · 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 observation, interview, and record review, the facility failed to a.) ensure the rights of the resident to receive effective and accessible means of communication and b.) ensure the residents were treated with respect and dignity by not passing out meals to residents sitting together at the same time. These failures affected two residents (R55 and R59) in a total sample of 19 residents reviewed for resident rights.Findings include: On 08/12/2025 at 12:03PM, surveyor located on the second floor of the facility located in the dining room. Surveyor observes meal trays being dispersed to residents sitting in the dining room. R72 and R55 observed seated at the same table in the dining room awaiting their lunch meal. R72 was served his lunch meal at 12:04PM and began eating his lunch meal. R55 did not have a meal tray and was not actively eating. V7 (CNA), V9 (CNA), V10 (CNA), and V11 (CNA) observed passing meal trays to other residents in the facility as they removed their tray off the meal cart. At 12:11PM,…

  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 · D2025-08-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for 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 observation, interview and record review the facility failed to ensure splints were applied as ordered by physician for 2 (R6 and R78) of 3 residents reviewed for limited range of motion in a sample of 19. The findings include: On 8/12/2025 at 11:17AM Observed R6 sitting up on wheelchair in her room, alert and oriented x 3, verbally responsive with limited ROM (range of motion) on Right arm no device in place. R6 said she broke her wrist due to fall incident. She said staff used to apply splint on her right hand but lately it was not applied. R6 said unable to recall the last time it was applied. Multiple observations conducted with R6 on 8/12/25 between 11AM to 2PM and on 8/13/25 between 10AM to 11:30AM, R6 was not wearing Right hand splint. R6's face sheet showed admission date on 6/8/23 with diagnoses not limited to Paroxysmal atrial fibrillation; Unspecified fracture of upper end of right radius; Essential (primary) hypertension; Age-related osteoporosis; Bilateral primary osteoarthritis of knee.MDS…

  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.

Fines & penalties

$245,827 in federal fines across 4 penalties. 2 Medicare payment denials on record.

• $111,930 — penalty dated 2026-03-26
• $74,003 — penalty dated 2024-12-19
• $33,023 — penalty dated 2024-09-06
• $26,871 — penalty dated 2024-04-26
• Medicare payment denial — starting 2025-01-14 for 16 days
• Medicare payment denial — starting 2024-05-17 for 21 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to LINEAGE HEALTHCARE — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 11 rows in the source record cover these 5 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.

About 97% 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 $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in IL