Winston Manor Cnv & Nursing
2155 West Pierce, Chicago, IL 60622 · For profit - Corporation · 180 certified beds · (773) 252-2066 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- 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
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (37) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 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 fell from 4 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 0.7% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.6% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 71.2% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 1.7% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.1% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.8% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 2.4% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 48.8% | 21.7% | 17.1% | worse |
| Short-stay residents given the seasonal flu vaccine | 83.0% | 63.1% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.56 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.72 | 2.22 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Staffing
How full it usually is: this home is certified for 180 beds and averages 144.9 residents a day — about 80% occupied, or roughly 35 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 1.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.84 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 1.29 hrs/resident/day on weekends vs 1.43 on weekdays — 10% thinner on weekends. RN hours go from 0.27 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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.
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.
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.
37 citations, most serious first. The 15 most serious are shown; the remaining 22 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-08-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 upon interviews and record review the facility failed to: conduct head counts (every two hours); failed to provide supervision for one resident (R7) in the sample; failed to follow Doctor's pass order for one resident (R5); and failed to implement the elopement and pass policies for three residents in a sample of 15 (R5, R6 and R7). These failures resulted in an immediate jeopardy and has the potential to affect 123 residents that reside in the facility.An immediate jeopardy began on 8/9/25 at 9:00 am, when R6 left the facility unauthorized and continued with subsequent failures that led to R5 and R7 also being away unauthorized.On 8/14/25 at 3: 47.pm, V1 (Administrator) and V20 (Regional Consultant) were notified of the Immediate Jeopardy and the IJ template was presented.On 8/19/25 an acceptable removal plan was accepted after revisions to other removal plans that were submitted on 8/18/2025.The immediacy was removed on 8/19/25, however deficiency remains at a level two because more time is needed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2026-01-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 review, the facility failed to ensure that the residents' bathroom floor was dry and free of a liquid substance. This failure has resulted in one resident (R1) slipping on the bathroom floor and sustaining fractures to her ankle. Findings include:R1 is [AGE] year-old with diagnoses including but not limited to: morbid obesity, epilepsy, vitamin D deficiency, type 2 diabetes mellitus and hypertension.R1 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.On 1/5/26 at 2:43 PM, R1 stated the following, I was discharged from the hospital on October 9, 2025, and am now at a different nursing facility. My ankle was broken in three places while in the last nursing home (named facility). I was going to the restroom in the middle of the night about 2:00 AM. The bathroom is down the hall from my bedroom. I was walking into the bathroom and there was no light or wet floor sign. The floor was really wet with water. I slipped and fell and began to yell…
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.
- Actual harm · Gcited before2025-12-31 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 prevent resident to resident verbal and physical abuse for one [R1] out of three residents reviewed for abuse. This resulted in R1 sustaining physical pain and mental anguish.Findings Include: R1's clinical record indicates the following in part: R1's medical diagnoses of post -traumatic stress disorder, chronic obstructive pulmonary disease, anxiety disorder, schizoaffective disorder, and overactive bladder.R2's clinical record indicates the following in part: Medical diagnoses: Schizoaffective disorder and major depressive disorder.R2's progress notes in part:V6 [Licensed Practical Nurse] note:12/26/2025 3:46 AM Note Text: This writer heard loud yelling in R2's room around 1:45 AM. R2 noted to be verbally aggressive with her roommate [R1]. R2 pulling back her roommate privacy curtains, playing loud music on her phone and putting on bright lights. R2 noted to be highly agitated. This remains to be a threat to staff and other residents. resident sent…
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.
- Actual harm · Gcited before2025-05-15 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 document review the facility failed assure the resident right to be free of physical abuse in 1 of 3 (R1) residents in a total sample of 8 residents. This failure resulted in R1 having bleeding lips, bump to right temporal area and feelings of fearing for his life. Findings include: The following incident took place on 4/28/25, around dinner time in the facility dining area. R1 is a [AGE] year-old male with diagnoses including Schizophrenia, Seizures, Depression, Scoliosis and Post-Traumatic Stress Disorder. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview of Mental Status) score of 15/15. R1 is care planned for including alteration in mental health function due to Schizophrenia and Depression. On 4/28/25, R1 was involved in a physical and verbal altercation with another resident R2. The altercation resulted in R1 having bleeding on lips and bump to right temporal area. R2 is a [AGE] year-old male resident with diagnoses including Schizoaffective Disorder,…
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.
- Actual harm · Gcited before2025-04-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 prevent and protect residents from physical abuse. This failure affected 2 (R1 and R2) out of 7 residents reviewed for abuse. R1 and R2 had a brawling incident on 3/28/25 that resulted in R2 having a nosebleed. The findings include: R1's admission record showed admission date on 2/24/2025 with diagnoses not limited to Schizophrenia, Insomnia, Anorexia, Attention-deficit hyperactivity disorder, predominantly inattentive type. MDS (Minimum Data Set, dated [DATE] showed R1's cognition was intact. R2's admission record showed admission date on 1/13/2025 with diagnoses not limited to Schizophrenia, Bipolar disorder, Depression, Essential (primary) hypertension, Insomnia. MDS dated [DATE] showed R2's cognition was intact. On 4/20/25 at 9:22AM R2 sitting on the side of the bed, alert and oriented x/times 3, verbally responsive. R2 stated R2 has been residing in the facility since mid-January 2025. He (R2) is ambulatory with steady gait, no assistive device.…
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.
- Potential for harm · E2026-06-17 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 provide clean bathrooms and an environment free of urine, feces and body odors. This applies to 15 residents (R1, R2, R3 and R6 through R17) of 17 in the sample reviewed for safe, clean and homelike environment. Findings include: OBSERVATIONSUpon exiting the elevator of the 4th floor, it smelled like strong bodily, urine and feces odors. On 6/15/2026 at 11:44 AM, the small 4th floor handicap bathroom on the left side of the hallway smelled of strong bodily odors, urine and feces. There were brown-yellowish substances that hardened or dried in drizzling formation from the rim of the toilet seat to the floor. The entire hallway smelled of those strong odors extending from the elevator going left down the hall to the last room next to the window. Two rooms from the window contained a visibly open portable toilet next to the resident's bed. On 6/15/2026 at 12:38 PM, V4 (Housekeeper) who was cleaning the 4th floor handicapped bathroom could not smell the odors in the bathroom or throughout the hallway left 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.
- Potential for harm · F2026-04-20 · tag F0583 — failed to protect personal privacy — widespreadKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and records review, the facility failed to ensure the confidentiality and security of residents' medical records. This failure has the potential to affect all 143 residents residing in the facility.Findings include:On 04/18/2026 at 12:22PM, V8 (Medical Records/Transportation) stated medical records are stored in the basement. During basement (gym) tour with V8, the door to the gym was not locked. Upon entering the gym, observed boxes upon boxes filled with medical records. The boxes were not sealed and were placed randomly around the gym. Some of the medical records papers observed spilling out of the boxed on to the floor. The medicals showed identifying medical and personal information of residents with different dates of when residents were in the facility. The gym was observed disorganized and filled with boxes and other miscellaneous items.V8 stated he found the gym piled with documents like this when he started working at the facility years ago. V8 stated he oversees thinning resident charts when they become too full. He puts the thinned…
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.
- Potential for harm · F2026-04-20 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 a.) ensure medications were locked and secured while unattended, b.) ensure controlled substance medications were double-locked and secured while unattended, and c.) properly waste and discard expired medications and controlled substance medications. These failures have the potential to affect all 143 residents residing in the facility reviewed for medications stored in the facility. Findings include: On 04/18/2026 at 12:43PM, V8 (Medical Records/Transportation) states he observed resident's medication stored inside of the basement in the facility. V8 states the medications are stored in an unlocked room although there is supposed to be a lock on the basement door. V8 states this door is accessible to all of the staff in the facility. V8 states resident's medication should only be accessible to people who are authorized.On 04/18/2026 at 12:52PM, surveyor located at the basement door, which is located down the hall from the kitchen and laundry room. Surveyor located at the basement door with V2 (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.
- Potential for harm · Dcited before2026-02-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 record review, the facility failed to ensure that two residents (R3 and R14) were free from verbal abuse. This failure has affected two of four residents reviewed for abuse. Findings include:R3 is [AGE] year old with diagnosis including but not limited to: schizophrenia, generalized anxiety disorder, neuralgia and neuritis.R3 has a BIMS (Brief Interview of Mental Status) score of 14, which indicates cognitively intact.R14 is [AGE] year old with diagnosis including but not limited to: major depressive disorder, schizoaffective disorder, essential hypertension and hidradenitis suppurativa.R14 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact.R4 is [AGE] year old with diagnosis including schizoaffective disorder and essential hypertension. On 2/10/26 at 10:58 am, V1 (Administrator) stated the following, R4 was sent out to the hospital today for aggressive behaviors towards other residents. It was just reported to me that on yesterday (2/9/26), R4…
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.
- Potential for harm · Ecited before2026-01-08 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a homelike environment for the residents. This failure applies to all 139 residents in the facility. Findings include: On 1/5/26 at 2:43 PM, R1 stated the following, The bathrooms and shower rooms in this facility are terrible and do not seem to be up to code. The showers never seemed to be cleaned and sometimes do not have shower curtains. There is also peeling drywall in the bathrooms. On 1/5/26 between 3- 3:30 pm, Surveyor conducted tour of second, third, and fourth floor residents' bathrooms. At that time, the following was noted: On 1/5/26 at 3:02 pm in second floor shower room, shower walls were noted with a black and brown substance; at 3:15 pm in the third-floor shower room, shower walls were noted with black and brown substance. Surveyor also noted a hole in the shower room ceiling with dry wall and paint peeing from ceiling and walls; and at 3:26 pm in the fourth-floor shower room, the shower walls were noted with a black…
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.
- Potential for harm · Dcited before2025-12-31 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their Abuse Reporting Policy and report allegations of abuse within two hours of the incident for one [R1] out of three residents reviewed for abuse.Findings Include: Reviewed facility's IDPH Initial Report for incident 12/26/25 [R1and R2].Dated: 12/30/25Time: 10:33 [NAME] 12/30/25 at 11:40 AM, R1 stated, On Christmas night, I was sleeping when my roommate [R2] hit me all in my back, everywhere on my body. Then R2 started throwing items at me, and some of the items hit me on my arm. R2 was cursing at me and yelling, she called me names I never been called before. I finally was able to get out of bed, and then I was yelling and screaming for help. I got out of bed and grabbed my walking cane to help me walk so I could get out of the room. R2 then tried to grab my cane out of my hands as she was pushing the cane towards my face trying to hit me with my own cane. I was holding on to my cane for my life. I knew if R2 got my cane she was going to bust…
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.
- Potential for harm · Dcited before2025-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a homelike environment for two (R3 and R4) out of three residents reviewed for homelike environment in a total sample of 4 residents.The findings include:On 08/26/2025 at 11:21 AM, surveyor observed a hole on the ceiling and paint chip in R3's room. There was a musty smell, and a blue blanket placed on the floor. R3 stated, the water leaks when it rains, and a bin must be placed to help collect the water. R3 stated he has told V4 (Maintenance Director) to fix it, but nothing has been done. On 08/26/2025 at 12:07 PM, V4 was first made aware of the water leak in R3's room approximately 1 1/2 months ago. V4 told V5 (Regional Maintenance Director) about the leaking from the walls in R3's room. He let him know that there was a hole in the wall in room [ROOM NUMBER]. V4 stated he has not seen any vendors come to the facility to address these issues. V4 stated no residents should be in the room under these conditions and will require a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-25 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interviews and record review, the facility failed to report that one newly admitted resident (R7) eloped from the facility; and failed to report that two residents (R5 and R6) left the facility unauthorized and did not return to the facility. This failure has affected three of fifteen residents in the sample and has the potential to affect all 123 residents that reside in the facility.R5 is a [AGE] year-old male with diagnoses of Schizophrenia, schizoaffective disorder, essential hypertension, tachycardia, and chronic obstructive pulmonary disease.R6 is a [AGE] year-old male with diagnoses of schizoaffective disorder, suicidal ideations, acute embolism, and thrombosis of unspecified deep veins of bilateral lower extremity, Gastro-esophageal reflux disease.R7 is a [AGE] year-old male with diagnoses of bipolar disorder, major depressive disorder, generalized anxiety, tachycardia, insomnia, and suicidal ideations.During investigation on 8/12/2025 at 11:15 AM, V1 (Administrator) stated the following, R5…
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.
- Potential for harm · Dcited before2025-08-25 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview and record review, the facility failed to develop a person-centered behavior care plan to address the resident's mental and psychosocial needs in an effort to attain or maintain the resident's highest practicable mental and psychosocial well-being. This failure affected 1 (R8) resident reviewed for care planning in the total sample of 15 residents. Findings include:R8's admission Record documented that R8's initial admission was on 07/09/2025; and R8's diagnoses: (include but not limited to) schizoaffective disorder, depression, and mild intellectual disabilities. R8's (08/15/2025) care plan documented, in part SOCIALLY INAPPROPRIATE/ MALADAPTIVE BEHAVIORS. displays socially inappropriate and maladaptive behavior. A history of dysfunctional behavior, mental illness diagnoses, anger, agitated depression, Restless/agitated behavior (rocking, picking, banging, etc.). Of note, inappropriate/maladaptive behavior care plan was initiated on 08/15/2025, the day this surveyor requested for R8's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-07 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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 review, the facility failed to ensure that COVID vaccinations, consents and education were documented for four residents. This failure has the ability to affect all 122 residents that reside in the facility. Findings include:R6 is [AGE] years old with diagnoses including, but not limited to: paranoid schizophrenia, bipolar disorder, other asthma, gastro-esophageal reflux disease without esophagitis, and hypothyroidism.R7 is [AGE] years old with diagnoses including, but not limited to: schizophrenia, anxiety disorder, essential hypertension, vitamin D deficiency and vitamin B12 deficiency anemia.R8 is [AGE] years old with diagnoses including, but not limited to: major depressive disorder, panic disorder, hyperlipidemia, dorsalgia and prediabetes.R9 is [AGE] years old with diagnoses including, but not limited to: schizoaffective disorder, essential hypertension, depression, and anxiety disorder.During investigation on 8/4/2025 at 2:15 PM, V5 (Regional Administrator) stated, I spoke…
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.
Show the remaining 22 citations
- Potential for harm · Dcited before2025-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 follow their elopement policy and procedure consistently with professional standards of practice placing the resident's health and safety at risk for one (R1) resident out of three residents reviewed in a total sample of three. Findings include: On 04/29/2025, at 12:19 PM, V4 (Registered Nurse) states that R1 is alert and oriented but is forgetful. V4 states that R1 is ambulatory with a steady gait and is a smoker. V4 was informed that R1 eloped this past Friday on 4/25/25, during the 10:00 AM smoking break despite someone monitoring the residents. V4 said the police brought R1 back, but he continued to be verbally aggressive and unpredictable. The nurse that evening sent him out per doctor ' s order. On 4/29/2025, at 12:58 PM, V5 (Social Services Director) states that the smoking times are 10:00 AM, 2:00 PM, 4:00 PM, and 6:00 PM. V5 states that the smoking area consists of outside benches. It is not enclosed. It is an open area and at least one staff…
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.
- Potential for harm · E2025-04-21 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 follow their abuse prevention program policy and procedure to check and review the criminal history background check within 24 hours of admission for one (R2) out of seven residents reviewed for abuse, and to ensure two staff (V8, V16) were educated and fully understood their abuse prevention program policy and procedure. This failure had the potential to affect all 48 residents residing on the fourth-floor unit. Finding Include: On 4/20/25 at 9:32 AM, interviewed V8 (Agency Licensed Practical Nurse) and stated she is the nurse in charged on the fourth floor. V8 stated it's her first day in the facility. Surveyor asked V8 about the facility's abuse policy. V8 stated she does not know who the abuse coordinator is and who to report abuse to. V8 stated she never received any abuse in-service or education. V8 stated she is the only nurse in charged for all the residents on the 4th floor. The facility's Abuse Prevention Program Facility Policy and Procedure…
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.
- Potential for harm · Dcited before2025-04-13 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 prevent and protect a resident from staff to resident abuse. This failure affects one (R2) resident out of four residents reviewed for abuse. Findings include: R2 is no longer in the facility and was reviewed as a closed record. R2's Face sheet documents that R2 has diagnoses not limited to: schizophrenia, insomnia, and attention deficit hyperactivity disorder. R2's MDS/Minimum Data Set, dated [DATE], documents that R2 is alert and oriented with a BIMS/Brief Interview for Mental Status of 15/15, indicating that R2 is cognitively intact. R2 requires supervision and set up assist with ADL/Activities of Daily Living care. R2 is continent of bowel and bladder and ambulates via walking. On [DATE], at 12:34 PM, R1 states 2 days ago on [DATE], he witnessed V3 (Social Services Director/SSD) pull R2 out of a chair causing R2 to fall on the floor. R1 states he was standing outside of V3's office door on the first floor of the facility and witnessed the entire…
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.
- Potential for harm · Fcited before2024-06-27 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 facility policy regarding wearing personal protective equipment (PPE) during manual handling of linen during sorting/rinsing and storing clean linen in a protected area. This failure has the potential to affect all 77 residents residing in the facility based on daily census dated 06/24/24. Findings include: On 06/25/24 at 11:35 AM, met with V18 (Housekeeping/Laundry) in the laundry room located on the 1st floor. V18 stated V18 has been working at the facility for 18 years, and usually works the day shift by himself. Observed large industrial fan blowing air at full blast aimed toward the dirty/clean work areas. There was no physical barrier separating the dirty/clean work areas. A box of gloves and masks observed by the door. No gowns or disposable gowns observed in the laundry area. A load of laundry was washing in the industrial clothing washer. Observed cleaned linen items folded and stored under a long metal table which were not covered with any type of protective covering. Surveyor could see…
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.
- Potential for harm · Ecited before2024-06-27 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to provide a safe environment by not providing covers or guards for florescent tube lights located in over the head wall lights behind resident's bed. These failures affected seven residents (R8, R22, R36, R39, R46, R55, R70) when reviewed for environment in the sample of 21 residents. Findings include: R36 has diagnoses of but not limited to Chronic Obstructive Pulmonary Disease, Schizophrenia, Seizures, Hyperlipidemia, Hypertension, Diverticulitis, Obesity, Gastro-Esophageal Reflux Disease. R36's BIMS dated 04/30/24 documents score of 15/15 indicating intact cognition. On 06/24/24 at 10:42 AM, observed R36's over the head wall light with exposed florescent tube light. The florescent light tube had no cover or guard over it. R36 stated R36 uses the over the wall light behind R36's bed at night when R36 reads because the main light in the ceiling is too bright and R36 does not want to keep R36's roommates up. R36 stated that light behind R36's bed has never had a plastic cover or guard covering the light bulb.…
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.
- Potential for harm · Dcited before2024-06-27 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to communicate to the primary physician and follow Neurology recommendation for 1 (R7) resident out of the final sample of 21. Findings Include: R7's electronic health records show R7 has diagnoses not limited to Schizoaffective Disorders, Schizophrenia, and Drug Induced Subacute Dyskinesia. R7's physician orders show R7 is receiving antipsychotic medication Clozapine. R7's Neurology Clinic's AFTER VISIT SUMMARY dated 4/9/24 shows R7 was examined by V24 (Medical Doctor) for Tardive Dyskinesia and recommended speech therapy for R7. R7's physician orders from April 2024 does not show a referral for Speech Therapy was ordered. R7's progress notes dated 4/9/24 at 1:06 PM reads, resident came back without follow up apt. No documentation that shows V24's recommendation was communicated and followed-up with V25 (Primary Physician). On 6/24/24 at 12:30 PM, V2 (Director of Nursing) stated that after the resident comes back from a specialist doctor's appointment, the expectation is for the nurse to read the after visit summary to 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.
- Potential for harm · Dcited before2023-08-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Based on interview and record review, the facility failed to identify, assess, develop, and implement a sexual intimacy care plan for one of four residents (R1) reviewed for care plans. Findings include: R1's medical record (Face Sheet, MDS-Minimum Data Set of 8.9.2023) documents R1 is cognitively intact 56- year-old admitted to the facility on 1.7.2019 with diagnoses including but not limited to: Schizoaffective Disorder, Depressive Type; Schizophrenia, Asthma, Morbid (Severe) Obesity Due to Excess Calories, and Type 2 Diabetes Mellitus. On 8.24.2023 at 1:38 PM, V4 (Social Service Director) stated that V4 had interviewed planned for R2 to come to R1's room to have sex that night. R1 said R2 came to R1's room, approached V3 on 8.22.2023 around 3:00 PM and that R2 admitted to having had sex with R1 on 8.21.2023 after planning with R1 earlier in the day. On 8.25.2023 at 10:09 AM V10 (PRSC-Psychiatric Rehabilitation Service Coordinator) said she thought R1 had a boyfriend. V10 stated that a couple of month ago R1 asked V10 for some condoms and R1 seemed excited about the prospect 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.
- Potential for harm · Dcited before2023-08-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 and implement interventions to address the potential for nicotine withdrawal for one of three residents (R3), reviewed for smoking. The failure resulted in R3 experiencing abdominal pain and anxiety. Findings include: R3's medical record (Face Sheet, MDS-Minimum Data Set of 8.9.2023) documents R3 is a [AGE] year-old moderately cognitively impaired resident initially admitted to the facility on 5.6.2021 with diagnoses including but not limited to: Hypertensive heart disease without heart failure, Schizoaffective disorder, bipolar type; Hyperlipidemia, and Major depressive disorder, recurrent, unspecified. On 8.24.2023 at 5:07 PM, R3 agreed to speak with surveyor in resident's room. R3 said some residents smoke in the bathroom down the hallway from her room; her roommate, R10, was smoking in their room while R3 was present. R3 said she was told on Sunday (8.19.2023), because she (R3) was smoking in her room, she would not be able to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 provide supervision to protect one resident (R1) out of 4 residents reviewed for supervision. This failure resulted in R1 and R2 allegedly meeting in R1's room and engaging in an inappropriate arrangement. Findings include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Schizoaffective Disorder, Depressive Type, Schizophrenia, Asthma, Morbid (Severe) Obesity Due to Excess Calories, Hyperlipidemia, Hypertension, Type 2 Diabetes Mellitus, Long Term (Current) Use of Oral Hypoglycemic Drugs, Long-Term (Current) Use Of Injectable Non-Insulin Antidiabetic Drugs. MDS (Minimum Data Set) dated 08/09/23 document R1's BIMS (Brief Interview of Mental Status) score of 14 indicating intact cognition. R1 has care plan for potential Abuse/Neglect/Exploitation/Trauma dated 11/04/222 which documents in part R1 is an adult living with chronic health conditions, psychiatric illness, challenges, and it is determined that symptomatologic factors…
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.
- Potential for harm · E2023-05-19 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their policy for Advance Directives by not obtaining physician orders for two (R6, R44) residents and not addressing on the resident's plan of care, physician progress notes, physician's orders and in social service progress notes for 11 (R3, R6, R13, R14, R20, R24, R52, R54, R57, R65, R321) residents. These failures can potentially affect 13 residents in a sample of 22 reviewed for advance directives. The findings include: R44 initial admission date was on 6/17/2010 with diagnoses not limited to Chronic Obstructive Pulmonary Disease, Asthma, Heart failure, Atrial flutter, Schizoaffective Disorder, Cerebrovascular Disease, Peripheral Vascular Disease, Arthropathies, and Gastroesophageal Reflux Disease. On 5/16/23 at 10:34 AM R44 was observed up and about, ambulatory with steady gait. R44 is alert and oriented x 4, verbally responsive. R44 stated that he has been living in the facility for about 13 years. R44 minimum data set (MDS) 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.
- Potential for harm · Ecited before2023-05-19 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility (A) failed to ensure wheelchairs for two [R18, R21] residents were maintained to protect their safety, and (B) failed to ensure ceiling paint was free from watermarks, peeling falling paint in one [R11] resident's room, and the second-floor shower room. These failures have the potential to affect all 34 residents residing on the second floor. Finding include, On 5/16/23 at 11:15 AM, R11 asked surveyor to come and look in his room. On 5/16/23, at 11:20 AM, surveyor and V4 [ Certified Nurse Assistant] observed over R11's bed, the ceiling with watermarks and hanging peeling paint. Surveyor observed paint pieces on R11's floor near his bed. On 5/16/23 at 11:28 AM, R11 stated, The water use leak down on me in bed when it rained a while ago. R11 stated the maintenance man shut of the water pipe on the third floor. R11 stated now little pieces of peeling hanging paint from the ceiling falls on me when I'm lying-in bed all the time. I hope none of the paint falls in my eyes. R11 stated living under these conditions are bad. 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.
- Potential for harm · Ecited before2023-05-19 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
Based on interviews and record reviews, the facility failed to follow policy for comprehensive care plan to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's needs and problems for 13 (R3, R6, R13, R14, R20, R24, R42, R44, R52, R54, R57, R65, R321) residents reviewed for comprehensive care plan in a sample of 22. The findings include: R44's initial admission date was on 6/17/2010 with diagnoses not limited to Chronic Obstructive Pulmonary disease, Asthma, Heart Failure, Atrial Flutter, Schizoaffective Disorder, Cerebrovascular Disease, Peripheral Vascular Disease, Arthropathies, Gastroesophageal Reflux Disease. R42's admission date was on 8/19/2008 with diagnoses not limited to Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Gastroesophageal Reflux Disease, Hypertension, Psychosis, Hyperlipidemia, Anemia, Benign Prostatic Hypertrophy, Malignant Neoplasm of Prostate, Osteoarthritis. On 5/16/23 at 10:34 AM R44 was observed up and about, ambulatory with steady gait. R44 is alert…
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.
- Potential for harm · Ecited before2023-05-19 · tag F0880 — failed to prevent and control infections — patternProvide 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 their policy and cover clean laundry with a clean protective sheet. This has the potential to affect all 31 residents that reside on the fourth floor. Findings include: On 05/16/2023 at 11:15 AM, surveyors observed the fourth-floor linen cart at the nurses' station. A white sheet was on top of the linen cart but did not completely come down to cover the contents of the cart. Surveyor observed folded incontinence pads on the cart uncovered. On 05/17/2023 at 9:17 AM, surveyor observed V18 (Certified Nurse Aide) changing residents' beds. Surveyor observed the linen cart in the hallway not fully covered. Surveyor observed folded green sheets and incontinence pads uncovered. On 05/17/2023 at 1:51 PM, V19 (Laundry Staff) stated staff should keep clean linens and sheets covered during transport and storage. V19 stated linen carts on the floor should be covered with a clean white sheet. Facility's Laundry - Route & Process policy last revised 04/01/2020 documents in part: The clean laundry on the cart is…
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.
- Potential for harm · E2023-05-19 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure a functioning call light communication system was accessible to 3 residents (R12, R14, R68) of 22 residents reviewed. This failure has the potential to effect 34 residents residing on the second floor. Findings include: Surveyor observed on 5/16/23 at approximately 12:35 PM, R12s call light button not working. Surveyor notes R12s call light button requires pressing and holding down for it to work. Surveyor observed at approximately 12:53 PM, R14 pressed call light button, light above room door did not light. Surveyor observed at approximately 12:35 PM and 12:53 PM, no audible notification observed when testing R12, and R14 call light function. Surveyor observed at approximately 12:57 PM, R68 did not have a call light button/cord in the room at all. Surveyor observed on 5/17/23 at approximately 9:05 AM, no audible notification observed when testing R12, R14 and R68s call light function. On 5/16/23 at 12:40 PM, V5 (Registered Nurse) stated V5 thinks R12s call light is broken because the button should stay…
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.
- Potential for harm · E2023-05-19 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 provide effective pest control two [R11, R32] residents in the sample of 22. These failures have the potential to affect all 34 residents residing on the second floor. Findings include, On 5/16/23 at 11:15 AM, R11 asked surveyor to come and see the bugs in his room. On 5/16/23, at 11:20 AM, Surveyor and V4 [ Certified Nurse Assistant] observed bugs crawling on the floor near the heat unit. Surveyor observed a white box near the wall with live bugs stuck in the open box moving. On 5/16/23 at 11:24 AM, V5 stated, Those are roaches crawling around the heat unit and inside the box. I think the glue box is for mice. I will call housekeeping to clean the floor. On 5/16/23 at 11:28 AM, R11 stated, The roaches are bad at night, crawling all over the heat unit, and in my bed. The water use to leak down on me in bed when it rained. The maintenance man shut of the water pipe on the third floor. Now little pieces of peeling hanging paint the ceiling falls on me when I'm lying-in bed all the time. Living under these…
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.
- Potential for harm · D2023-05-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 call lights were within the residents reach for 2 (R14, R24) residents reviewed for accommodation of needs in a sample of 22. Findings Include: On 05/16/23 at 10:52 AM upon entering R14s room R14 was observed lying in bed with the call light located behind the headboard over the head of the bed. Surveyor asked R14 where the call light was located? R14 responded to tell you the truth, I don't know where the call light is. A few days ago, I fell, ended up on my knees and I called out for help. On 05/16/23 at 11:00 AM V4 (Certified Nurse Assistant) stated When I am making my rounds, I am checking to make sure everyone is ok, not harmed, awake or sleeping, if they are breathing, need assistance or need anything. I make rounds every 2 hours. R14 is supposed to use the call light. R14s call light is right here behind the head of the bed, it probably fell over and moved back. R14 can get in the wheelchair and sometimes R14 cannot because…
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.
- Potential for harm · Dcited before2023-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 identify and evaluate hazard(s) and risk(s) by not completing resident smoking safety risk assessments to ensure the environment is free from accident hazards. This failure can potentially affect two (R42 and R44) residents reviewed for smoking in a sample of 22. The findings include: R44 initial admission date was on 6/17/2010 with diagnoses not limited to Chronic Obstructive Pulmonary Disease, Asthma, Heart Failure, Atrial Flutter, Schizoaffective Disorder, Cerebrovascular Disease, Peripheral Vascular Disease, Arthropathies, Gastroesophageal Reflux Disease. R42's admission date was on 8/19/2008 with diagnoses not limited to Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Gastroesophageal Reflux Disease, Hypertension, Psychosis, Hyperlipidemia, Anemia, Benign Prostatic Hypertrophy, Malignant neoplasm of prostate, Osteoarthritis. On 5/16/23 at 10:34 AM R44 was observed up and about, ambulatory with steady gait. R44 is alert and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 policy and physician order related to applying left wrist splint for a resident diagnosed with Arthritis and De Quervain's Tenosynovitis (inflammation of tendons) to 1 of 1 resident (R33) for a total sample of 19 reviewed. Failures include: On 07/26/2022 from 10:20 AM to 01:16 PM V11 (Registered Nurse) stated, R33 is able to ambulate and with no limitation in moving his extremities. R33 stated that he has no concern as to his range of motion. R33 does not have his splint applied when seen from 10:20 AM till present. On 07/27/2022 at 09:48 AM. R33 was seen without left wrist/hand splint at 2nd Floor dining room while playing bingo. On 07/27/2022 at 11:22 AM. V4 (Registered Nurse) was informed that since yesterday morning R33 was seen without a splint on his left hand. V4 stated that the splint helps R33 with Arthritic pain, but he refused it. R33 was asked about not wearing his splint, R33 stated that nobody instructed him to use his left-hand splint today or yesterday. R33 sated the doctor told him to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-29 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 policy and physician order related to CPAP (Continuous Positive Airway Pressure) treatment to a resident diagnosed with Sleep Apnea (absence of breathing during sleep) to 1 of 1 residents (R33) for a total sample of 19 reviewed. This failure has the potential to affect 1 of 1 residents at risk for Sleep Apnea untreated. Findings include: On 07/27/2022 at 09:52 AM R33's CPAP was not seen on the bedside. R33 has an order for CPAP at bedtime. On 07/27/22 at 11:22 AM V11 (Registered Nurse) stated that R33's CPAP machine is in a cabinet at the nurse's station. But when asked to see the CPAP machine multiple times, V11 stated About the CPAP machine it was transferred to 4th floor to be used by another resident. V11 further stated that nursing staff will not be able to offer CPAP at bedtime when it is not available on the floor. On 07/27/2022 at 11:38 AM V2 (Director of Nursing) stated that prospectively she will inform the doctor because…
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.
- No harm found · Bcited before2024-06-27 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide the required 80 square feet per bed for 5 resident rooms out of 68 resident rooms in the facility. The findings include: On 6/24/24 at 9:53 AM V1 (Administrator) stated there are 5 rooms with less than the required square footage. On 6/25/24 at 10AM Surveyor rounded 5 rooms with V5 (Maintenance Director). V5 stated he started working in the facility on January 2, 2024. Observed 4 rooms were not occupied. R22, R23 and R46 occupied 1 room and stated no concerns with room square footage or size of room. They said they can move around the room with no concerns. Facility provided document titled List of rooms under room waiver documented in part: 4 resident rooms with square footage of 15 x 17 and 1 room with square footage 13 x 18. Facility document presented by V1, titled Illinois Department of Public Health Waiver Status Report and dated 06/20/96, documents in part, the facility has 5 rooms that do not have a minimum of 10 feet between walls or a wall and any built-in furniture, and the facility will…
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.
- No harm found · Bcited before2023-05-19 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, the facility failed to provide the required 80 square feet per bed for 5 resident rooms out of 68 resident rooms in the facility. This failure has the potential to affect six residents (R26, R27, R30, R39, R48, R67). Findings included: On 05/16/23, 5/17/23, and 5/18/23, during the tours on the unit, observations were made of room sizes. On 05/16/23 at 11:00 AM, V1 (Administrator) stated that the facility has a list of rooms under room waiver and provided surveyor with a list of the identified rooms including their square footage and number of beds. V1 stated the current residents living in these rooms have not requested to be changed to a different room and that some of the rooms are not filled to capacity. On 05/18/23 at 10:55 AM, R26 stated R26 can move around R26's room without restrictions and has no concerns about the space or size of the room. Observed R26 moving around in room without any limitations, obstacles, or environmental restrictions. On 05/18/23 at 11:00 AM, R30 stated R30 has been living in the same room since admitted to 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.
- No harm found · Bcited before2022-07-29 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations and interview, the facility failed to provide the required 80 square feet per bed for five resident rooms. Findings include: On 07/26/2022 at 10:08 AM V1 (Administrator) stated, I have a waiver form for some rooms that do not meet the 80 square feet requirement. V1 provided the survey team with the room waiver form with the following dates: 8/13/1994, 6/20/1996. There are a total of five rooms that are listed under the room waiver.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in IL
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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.
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 14E169. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-27, 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.