Smith Village

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.

67.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 318 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 44.4% 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 135 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 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 78 beds and averages 65.9 residents a day — about 84% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.27 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.12 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.49 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.74 hrs/resident/day on weekends vs 5.48 on weekdays — 13% thinner on weekends. RN hours go from 1.19 to 0.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%.

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

Inspection trend

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

Inspection deficiencies

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

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

23 citations, most serious first. The 15 most serious are shown; the remaining 8 are one tap away and print in full.

• Actual harm · G2026-05-16 · 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 an appropriate discharge for one resident reviewed for discharge practices by discharging the resident despite abnormal laboratory results indicative of dehydration. This deficient practice affected one (R1) of two residents reviewed for discharge. As a result, R1 was readmitted to the hospital within 48 hours of discharge with diagnoses of acute metabolic encephalopathy, likely secondary to a combination of dementia, dehydration, and urinary tract infection (UTI).Failure to ensure the resident was medically stable prior to discharge had the potential to result in worsening dehydration, delayed medical treatment, increased risk for hospitalization, and adverse health outcomes related to unresolved clinical conditions.R1 was admitted to the facility on [DATE] and discharged home on 2/18/2026. Her medical history includes fracture of left pubis, acute kidney failure, muscle wasting and atrophy, ataxic gait, type 2 diabetes mellitus, elevated white…

  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 · G2026-01-21 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to follow their abuse protocol for one resident (R1) out of four residents reviewed for abuse. This failure resulted in an employee cashing several of R1's personal checks without his knowledge/permission. Findings Include:R1's 7/26/2025, 19:12 admission Details reads: Arrived by other. admission mode: wheelchair. Living situation prior to admission: Other residential facility / assisted living / group home. Mental Status: Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking.R1's 9/4/2025 18:26 Health Status Note Text reads: Resident actively transitioning. Family visiting through shift. Hospice RN made aware and was coming to facility. Resident resting in bed. Oncoming shift aware to monitor.R1's 9/4/2025 19:20 Health Status Note Text reads: Resident being unresponsive and pulseless. Daughter /POA present. Dr. made aware.During interview on 1/15/26 at 5:00pm V5 (Assistant Executive Director) stated she received a message on her voicemail from the daughter of R1.…

  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 before2025-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that proper number of staff were used in transferring one of four residents (R1) to prevent accidental hazard in the sample who requires two persons assist in transfers from chair to bed or bed to chair. This failure affected R1 who was transferred from chair to bed by one staff instead of two. As a result, R1 sustained laceration of left lower leg, was sent to the hospital and the laceration required eighteen (18) sutures to be repaired. This has a potential to affect all 70-residents residing at the facility. Findings include: R1's medical record admission Record showed that R1 was originally admitted to the facility on [DATE] and the latest admission date was 08/26/24 with a diagnosis list that includes but not limited to Unspecified intracapsular fracture of the left femur, subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, syncope and collapse, unspecified atrial fibrillation, mixed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-02-13 · tag F0909 — failed to maintain a comfortable temperature — isolated
  Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
  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 bed frame is locked to the size of the mattress for the safety of one resident (R1) reviewed for injury. As a result, R1's left lower leg made contact with the loose bed frame during transfer into bed causing a laceration. R1 was sent to the hospital and the laceration was repaired with 18 sutures. This has the potential to affect all 70 residents residing in the facility. Findings include: R1's medical record admission Record showed that R1 was originally admitted to the facility on [DATE] and latest admission date was 08/26/24 with diagnosis list that includes but not limited to Unspecified intracapsular fracture of the left femur, subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, syncope and collapse, unspecified atrial fibrillation, mixed hyperlipidemia, ataxic gait, muscle weakness(generalized), muscle wasting and atrophy, major depressive disorder, single…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-07 · 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 record reviews, the facility failed to provide adequate supervision for 1 confused resident [R1] who is a high fall risk out of 3 [R1, R2, R3] residents reviewed for falls. This failure resulted in R1 being found on the bathroom floor bleeding to the back of the head. R1 was transferred to the hospital and R1 received laceration repair with staples. Findings Include: R1's clinical record indicates in part the following: R1 is a [AGE] year-old admitted to the facility on [DATE] with admitting medical diagnosis include but not limited to- right closed femur fracture, abnormal gait and mobility, weakness, cerebral infarction, aphasia following cerebral infarction, traumatic hemorrhage cerebral without the loss of consciousness, muscle wasting and atrophy, dementia with mood disturbance, mood affective disorder, fall on/from stairs, essential hypertension, and osteo-arthritis. R1's Minimum Data Set Brief Interview for Mental Status [BIMS] score [04] indicates R1 is severely cognitively…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-05-16 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect 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 interview and record review, the facility failed to notify the physician and residents' representatives when new treatments were initiated and failed to notify the physician of abnormal laboratory results for three (R1, R2 and R3) of three residents reviewed for notification of changes. This deficient practice had the potential to delay medical evaluation and treatment, limit resident and representative participation in care planning and informed decision-making, and place residents at risk for worsening conditions, avoidable hospitalization, and adverse health outcomes. R1 was admitted to the facility on [DATE] and discharged home on 2/18/2026. Her medical history includes fracture of left pubis, acute kidney failure, muscle wasting and atrophy, ataxic gait, type 2 diabetes mellitus, elevated white blood cell count, dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hyperlipidemia and essential (Primary) hypertension. R1's Physician Order Sheet documents an…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-26 · 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 ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 7 residents prescribed controlled substances on the 3J medication cart and 5 residents prescribed controlled substances on the 2J medication cart.Findings include: On 09/30/2025 at 8:41AM accompanied by V14(LPN/Licensed Practical Nurse) reviewed the second-floor [NAME] medication cart's Controlled Substance Shift to Shift Count form for September 2025, this form is used by the facility for shift change accountability for controlled substances. The Nurse Off initial box was left blank for: September 17, 2025, 6:30am, - Nurse Off On 09/30/2025 at 9:36AM accompanied by V15(LPN/Licensed Practical Nurse) reviewed the third-floor medication cart's Controlled Substance Shift to Shift Count form for September 2025, this form is used by the facility for shift change accountability for controlled…

  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 before2025-11-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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 ensure that kitchen staff perform proper hand hygiene; failed to label and date dry storage food and left-over prepared foods; and failed to discard foods past their discard date. These failures have the potential to affect 60 residents consuming oral diets from the facility kitchen.Findings include:On 9/29/2025 at 9:39 AM, this surveyor initiated the kitchen tour with V3 (Dietary Director). On 9/29/2025 at 9:45 AM, this surveyor viewed the dry storage room with shelving units containing stored food items in packages, containers and boxes. Orange colored labels with a date are noted attached to most dry food items. V3 stated that the orange sticker is the date of the delivery date of the food item, and V3 shows this surveyor the label machine hanging in the dry storage room with the orange stickers. On 9/29/2025 at 9:47 AM, on the shelving unit in the dry storage room, this surveyor observed 2 boxes of bananas. This surveyor is wearing surgical face mask and can smell the ripe bananas. When asked when the…

  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 · Ecited before2025-11-26 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to perform hand hygiene before and after performing direct care to residents; failed to perform hand hygiene during dining; and failed to conduct proper respiratory etiquette during dining while feeding a resident. These failures affected three residents (R1, R5, and R27) in a total sample size of 36, and has the potential to affect all 23 residents that reside on the 3rd floor.Findings include: On 09/29/25 at 11:34am V7 (Certified Nursing Assistant/CNA) performed care (repositioning and fixing under pad) to R1 without performing hand hygiene or donning gloves. V7 then removed soiled napkin from R1's bed and exited the R1's room. V7 observed entering R5's room and placing soiled napkin from R1's room on R5's dresser. V7 observed donning gloves without performing hand hygiene and assisting R5 to the restroom. V7 then observed removing gloves, picking up soiled napkin and walking to dining area. V7 observed placing soiled napkin in a basket then…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-09-19 · 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 ensure foods were labeled, dated and maintained to prevent the spread of foodborne illness to all residents receiving oral nutrition. This failure has the potential to affect all residents. Findings include: On 9/15/2024 at 9:54am surveyor observed a 1.5 lb. container of uncovered beef patties (sliders) out of its original packaging and a roll of pepperoni wrapped in plastic with no received date or discard date. There was a bag of tilapia fish, not individually wrapped but open to air in its original container with no discard date. On 9/15/2024 at 9:57am V4 (Dietary Manager) stated no, they (beef patties-sliders) should not be in the freezer uncovered and all food items should be covered and have a received and discard date because you will not know when to discard the items. On 9/15/2024 at 10:02am surveyor observed two 5-gallon tubs of chocolate and pecan ice cream with the top not secured on the tubs in the dairy freezer. On 9/16/2024 at 10:17am surveyor observed (2) 1.5-gallon containers of Bread Battered…

  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 before2024-09-19 · tag F0814 — failed to dispose of garbage properly — widespread
  Dispose of garbage and refuse properly.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure the garbage dumpster lids were closed. This failure has the potential to affect all residents residing in the facility. Findings include: On 9/16/2024 at 10:11am surveyor observed a blue garbage dumpster with both lids open. Surveyor observed V4 (Dining Service Manager) close both lids on the blue garbage dumpster. On 9/16/2024 at 10:11am V4 (Dining Service Manager) stated, no, the lids should not be open, but the CNAs use the dumpsters too. On 9/18/2024 at 12:30pm V8 (Environment Service Director) stated that the dumpster lids should be closed on the dumpsters. Policy titled Disposal of Garbage and Refuse with an implemented date of 2/10/2023, documents, in part, Garbage and refuse containers shall be covered when not in use and 7. Containers and dumpsters shall be kept covered when not being loaded. Undated job description titled EVS Director documents, in part, Plans, organizes and directs all functions of Environmental Services to provide for a safe, clean, functional and comfortable environment,…

  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 · Ecited before2024-09-19 · 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

  Based on observation, interview, and record review the facility staff failed to complete the controlled substance shift to shift count form which is utilized to complete a shift-to-shift count for controlled substances. This failure has the potential to affect all 27 residents on the second floor and all 16 residents on the first floor. Findings include: On 09/17/2024 at 10:00AM with V13(RN/Registered Nurse) reviewed the second-floor medication cart's Controlled Substance Shift to Shift Count form for September 2024, this form is used by the facility for shift change accountability for controlled substances. The Nurse On and/or Nurse Off initial boxes were left blank for: September 08, 2024, PM Shift, - Nurse Off September 09, 2024, AM Shift-Nurse On September 11, 2024, PM Shift-Nurse Off On 09/17/2024 at 10:15AM with V14(RN/Registered Nurse) reviewed the first-floor medication cart's Controlled Substance Shift to Shift Count form for September 2024, this form is used by the facility for shift change accountability for controlled substances. The Nurse Off initial box was left blank…

  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 before2024-09-19 · 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 observation, interview, and record review the facility failed to ensure a resident (R21) with a chronic wound was placed on Enhanced Barrier Precautions (EBP). This failure has the potential to affect all 27 residents on the second floor. Findings include: On 09/16/24 at 9:50 am, V1 (Administrator) presented a facility census of 27 residents on the second floor. R21's face sheet shows that R21's has diagnosis which include but not limited to unspecified malignant neoplasm of skin and other symptoms and signs involving the musculoskeletal system. R21's Brief Interview for Mental Status (BIMS) dated 06/24/24 shows that R21 has a BIMS score of 6 which indicates that R21 has some cognitive impairments. On 09/17/24 at 9:52 am, Surveyor observed R21 in bed resting with no EBP sign or Personal Protective Equipment (PPE) bin inside or near R21's room. On 09/17/24 at 9:54 am, V9 (Registered Nurse, RN, Wound Care Nurse) and V10 (Certified Nursing Assistant, CNA) were observed performing high-contact resident care activities (wound care to R21's left ischium stage 4 pressure ulcer…

  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 before2024-09-19 · 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

  Based on observation, interview and record review, the facility failed to ensure that one resident's (R11) urinary catheter drainage bag was covered with a privacy cover. This failure affected one resident (R11) in a sample of 44 residents reviewed for dignity. Findings include: On 09/17/2024 at 08:49am while in the hallway upon entry into R11's room, a urinary catheter drainage bag was observed hanging off the right-side lower bed frame of R11's bed. R11 was observed lying in the bed. R11's urinary catheter drainage bag contained yellow urine and was not covered with a privacy bag. R11's bed is the only bed in the room and the uncovered urinary catheter drainage bag was visible to others walking past R11's room door when the door was open. On 09/17/2024 at 8:53am this observation was brought to the attention of V12(LPN/Licensed Practical Nurse). V12 stated the urinary catheter drainage bag should be covered with a privacy bag. On 09/17/2024 at 8:54am observed V12(LPN) placing R11's urinary catheter drainage bag into a blue privacy bag. On 09/18/2024 at 11:10am V2(DON/Director 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-09-19 · tag F0803 — failed to meet residents' dietary needs — isolated
  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

  Based on observation, interview, and record review the facility failed to follow a resident's diet order for fluid restriction. This failure affected one resident (R37) out of 44 residents in the sample. Findings include: R37's face sheet shows that R37's has diagnosis which include but not limited to acute on chronic diastolic (congestive) heart failure, chronic kidney disease and organ limited amyloidosis. R37's Brief Interview for Mental Status (BIMS) dated 08/19/24 shows that R37 has a BIMS score of 10 which indicates that R37 has some cognitive impairments. On 09/16/24 at 12:30 pm, R37's was observed in the second-floor dining room during the lunch meal. Surveyor observed R37 drink a 7.5 oz (ounce) can of ginger ale soda and then a 6.0 oz cup of water. Surveyor observed R37's diet card orders next to R37's lunch meal with the following dietary order documented in part: Diet Order: Regular texture no added salt, fluids thin. Notes Fluid restriction: provide the following only: 6 oz (ounces) water, coffee, juice, or soda- one of these options only . Alerts: 1500 mL (milliliter)…

  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

“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

$16,350 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $16,350 — penalty dated 2026-05-16
• Medicare payment denial — starting 2026-02-13 for 16 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.

Who owns this facility

CMS files one row per role, so the 12 rows in the source record cover these 6 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.

This home reported $1.9M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). 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