Nexus at Columbia

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.

38.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 54.0% 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 37 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 119 beds and averages 103.8 residents a day — about 87% occupied, or roughly 15 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.44 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 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 3.09 hrs/resident/day on weekends vs 3.58 on weekdays — 14% thinner on weekends. RN hours go from 0.35 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

46 citations, most serious first. The 19 most serious are shown; the remaining 27 are one tap away and print in full.

• Immediate jeopardy · J2026-04-30 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident for 1 of 1 (R2) resident reviewed for CPR in the sample of 6.This failure resulted in an Immediate Jeopardy that began on [DATE] and resulted in the death of R2, who had an unknown code status and was found breathless and unresponsive and did not receive lifesaving Cardiopulmonary Recusation efforts.On [DATE] at 11:39 AM V1, Administrator, V2, Director of Nursing (DON), and V9, [NAME] President of Clinical Operations, were notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on [DATE], but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.Findings Include: R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and had a medical diagnosis of Chronic Obstructive Pulmonary Disease, Cirrhosis of Liver,…

  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
• Immediate jeopardy · Jcited before2025-01-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent resident verbal and physical abuse for 1 of 8 residents (R2) reviewed of abuse in a sample of 8. This failure resulted in an Immediate Jeopardy on 12/19/24, when V6, R2's brother, who was known to have a history of abusing R2, was allowed to have unsupervised visits with R2 and verbally abused her. Subsequently, on 12/29/24, V6 verbally and physically abused R2. Using a reasonable person concept, this would have caused psychosocial harm resulting in feelings of being unsafe, sadness, fear, and humiliation. The Immediate Jeopardy began on 12/19/24, when the facility failed to prevent V6 from verbally abusing R2 and implement interventions to prevent future abuse. On 12/29/24, V6 again verbally and physically abused R2. On 1/7/25, at 11:00 AM, V2, Assistant Administrator, and V3, Director of Nursing (DON), were notified of the Immediate Jeopardy. The surveyors confirmed by interview and record review, the Immediate Jeopardy was removed on 1/9/25,…

  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
• Immediate jeopardy · Jcited before2022-11-18 · 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, observation, and record review, the facility failed to implement fall interventions for 4 of 10 residents (R3, R11, R55, R74) reviewed for falls in the sample of 33. Findings Include: 1. R55's Fall Care Plan, dated 10/25/22 and 8/2/22, documents R55 is at risk for falls related to impaired cognition, activities of daily living deficit, weakness, and medication. The goal will remain free of falls causing hospitalizations related to injury through next review. On 8/19/22 (interventions include), visual reminder in room and bathroom to use the call light, evaluate cause of falls, gather and assess information on past falls, (review) medication ordered, staff to assist resident with activity (and) set up (the) television. This care plan did not document a fall intervention for the fall of 6/15/22. R55's Minimum Data Set, (MDS), dated [DATE], documents R55 is severely cognitively impaired. For transfer and bed mobility she is an extensive assist of one staff person. R55's MDS also documents R55'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent resident-to-resident physical abuse in 1 of 4 residents (R2) reviewed for abuse in the sample of 5. This failure resulted in R2 feeling unsafe in the facility and being hit in the breast. Findings include: 1. R1's Undated Face Sheet documents R1 was admitted to the facility on [DATE], and has the following medical diagnoses: Metabolic Encephalopathy, Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct, Secondary Malignant Neoplasm of Unspecified Site, and Generalized Anxiety Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Undated Care Plan documents R1 is at risk for abuse and neglect related to interaction with staff and peers and poly-medication use. R1 has aggressive, inappropriate, attention-seeking, and/or maladaptive behavior. R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE], and has the following medical diagnoses Major Depressive Disorder, Bipolar…

  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 before2025-04-24 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to ensure residents wear treated in a dignified manner by providing timely toileting assistance and respecting the resident's right to a home-like environment for 2 of 6 residents (R1 and R4) reviewed for resident's rights in the sample of 6. This failure caused R1 to feel like V4 was mean to R1, resulting in R1 crying, and R4 feeling a little depressed. Findings include: 1. R1's Face Sheet, dated 4/23/2025, documents R1 has diagnoses including, but not limited to, Morbid Obesity, Need for Assistance with Personal Care, Weakness, Reduce Mobility, Depressive Disorder, and Anxiety Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and is dependent of toileting hygiene. The Facility's CNA (Certified Nursing Assistant) Staffing Assignment, dated 4/20/2025, documents V4 and V11 were assigned to R1's hall. It further documents V9 and V10 were assigned to 200 hall. On 4/22/2025 at 7:30 PM, V16, R1's sister,…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure a resident was free from abuse, from a resident with a history of prior altercations, for 2 of 2 (R2 and R5) residents reviewed for abuse in the sample of 6. This resulted in R2 receiving physical harm, facial bruising, including right cheek, bridge of her nose, and below both eyes and utilizing the reasonable person concept, this failure resulted in psychosocial harm by R2 yelling out in fear Hit me one more time and I swear. Findings Include: R5's Facesheet documents an admission date of 6/2/2023. Diagnosis include Dementia, Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Routine Healing, Chronic Obstructive Pulmonary Disease, Protein Calorie Malnutrition, and Cirrhosis of the Liver. R5's Minimum Data Set (MDS), dated [DATE], documents R5 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. R5 requires substantial/maximum…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe transfer was done for 1 of 3 residents (R3) reviewed for transfers in the sample of 6. This failure resulted in R3 being sent to the hospital and receiving 7 staples to his head. Findings include: R3's Physician Order Sheet for January 2024 documents a diagnosis of Unspecified Protein calorie malnutrition, Need for assistance with personal care, weakness, other reduced mobility, deforming dorsopathies, dysphagia, polyp of colon, barretts esophagus without dysphasia, disorientation, abnormal weight loss, Personal history of traumatic brain injury. R3 has an order for pureed diet, health shakes twice a day, super cereal at breakfast, and fortified pudding at lunch and dinner. Resident is also supposed to wear hip protectors every shift. R3's Minimum Data Set, dated [DATE], documents R3 was severely impaired for cognition. For eating he requires substantial /maximal assistance, dependent on staff for toileting, is dependent on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-08-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide 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 ensure respiratory therapy is administered with a physician's order and monitored during administration for 3 of 4 residents (R1, R2 and R3) reviewed for respiratory care in the sample of 7. This failure resulted in R2's oxygen blood saturation levels being low, emergency service being dispatched, and R2 being sent to local hospital for medical evaluation. Findings include: 1.R2's Physician Order Sheet (POS), dated August 2023, documents a R2 had diagnoses of Type 2 diabetes mellitus with diabetic neuropathy, weakness, need for assistance with personal care, acute on chronic systolic (congestive) heart failure, hepatic encephalopathy, acquired absence of left leg below the knee, cardiac arrhythmia, and aortic valve stenosis. R2's Physician Order Sheet did not have an order for R2 to receive oxygen. R2's Minimum Data Set (MDS), dated [DATE], documents R2 was moderately impaired for cognition for decision making of activities of daily…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-11-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their abuse policy. This failure placed residents at risk of both physical and verbal abuse from a resident with a known history of verbal and physical abuse toward other residents. This affected 4 of 4 residents (R39, R57, R63 and R240) in a sample of 33 reviewed for abuse. This failure led to R63 being afraid to be in R63's room due to verbal abuse from R57, R39's wound on face being re-injured and R240 being verbally and physically abused by R57. Findings include: 1. R39's admission Minimum Data Set, (MDS), dated [DATE], documents cognitively impaired and displayed no behaviors. R57's Quarterly MDS, dated [DATE], documents severely cognitively impaired and displayed no behaviors. R57's Care Plan, dated 6/9/2021 documents displayed symptoms towards others. Resident can become verbally and physically aggressive with others which includes staff and peers. There are no progressive interventions documented on R57's care plan since…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-30 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to report an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11.Findings include: 1-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was moderately cognitively impaired and ambulated via wheelchair. R4's Care Plan intervention last reviewed 2/12/26 documents R4 is at risk for abuse and neglect. On 4/30/26 at 8:37 AM, V5, Licensed Practical Nurse (LPN), stated R4 came to her and told her someone hit him, then showed her a bruise on his left arm. V5 called V1, Administrator, to tell her about the allegation. On 4/28/26 at 3:10 PM, R4 stated he was going down the hall the other day and asked R5 to move and she just punched him in the arm. He stated this was witnessed by V27, Certified Nursing Assistant (CNA), and another staff he cannot remember. On 4/29/26 at 1:30 PM, V1 stated she was not aware of R4'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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-30 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 thoroughly investigate an allegation of abuse for 1 of 3 residents (R4) reviewed for abuse in the sample of 11.Findings include: 1- R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was moderately cognitively impaired and ambulated via wheelchair. R4's Care Plan intervention last reviewed 2/12/26 documents R4 is at risk for abuse and neglect. On 4/29/26 at 8:37 AM, V5, Licensed Practical Nurse (LPN), stated R4 came to her and told her someone hit him and showed him a bruise on his left arm. V5 called V1, Administrator, to inform her of R4's allegation. On 4/28/26 at 3:10 PM, R4 stated he was going down the hall the other day and asked R5 to move when she just punched him in the arm. R4 had a light purple circular area on the back side of his left arm measuring approximately two inches in diameter. He stated this was witnessed by V27,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-20 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide showers for 4 of 4 (R1, R11, R12, R15) residents reviewed for Activities of Daily living in a sample of 15. Findings include: The facility's Resident Council Minutes, dated 12/5/2025, documents 400 hall not getting showers. On 2/18/2025 at 2:50 PM Requested January's shower documentation. As of 2/19/2025 at 4:21 PM the facility had not provided any shower documentation for January. 1. The facility's 400 Hall Shower Sheet documents R1's scheduled showers are on Wednesday and Saturday, day shift. R1's Shower/Bathe task documents R1 received a shower on 1/25, 2/13 and 2/17/2025. On 2/1, 2/5, 2/8, and 2/15 documents not applicable. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. On 2/10/2025 at 12:20 PM, R1 stated the shower room on 500 hall doesn't have heat and doesn't have hot water. R1 stated because of his size, he is not able to take a shower, because the 400 hall doesn't have a large enough equipment for 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-02-20 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 serve food at a palatable temperature for 4 of 4 residents (R13, R14, R15, R1) in a sample of 15. Findings Include: The (facility) Grievance/Concern reporting form, dated 2/6/2025, documents Resident council concerns relates to dietary. The resident Council met on 2/6/25. Most concerns were dietary, or food related. 4. The wire racks with room trays does not keep the food warm. The food is cold when the resident receives it. Investigation: met with regional dietary manager bases and lids to keep food warm. On 2/18/2025 at 12:40 PM, hall trays were prepared. Each tray had a lid, but no base. The plate was placed directly on the tray that was placed on a wire cart. The hall cart left the kitchen at 12:45 PM and sat at the nurse's station. First tray removed 12:48 PM and completed at 12:53 PM. Temperature tested on sample plate from the metal hall cart. The pasta and ground beef mix temped at 126 degrees and the green beans temped at 120…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-20 · tag F0580 — failed to tell family and doctor about changes — isolated
  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

  Based on interview and record review, the facility failed to notify the Power of Attorney of medication changes for 1 of 3 (R5) residents reviewed for notification in a sample of 15. Findings include: R5's Care Plan, dated 10/21/2023, documents PSYCHOTROPIC MEDS: (R5) requires the use of psychotropic medication, Risperidone to assist with managing mood and behavior related to DX (diagnosis) Huntington Disease; anxiety and metabolic encephalopathy. ANXIETY MEDS: (R5) requires the use of anxiety medication, Clonazepam and Ativan to assist with managing anxiety related to DX Huntington Disease; anxiety and metabolic encephalopathy. DEPRESSION MEDS: (R5) requires the use of depression medication, Fluoxetine and Mirtazapine to assist with managing depression related to DX Huntington Disease; anxiety and metabolic encephalopathy. R5's admission Record, not dated, lists Huntington's Disease as diagnosis. R5's Physician Order Sheet (POS), dated 11/09/24 Fluoxetine HCl Oral Tablet 20 MG (Fluoxetine HCl) Give 1 tablet by mouth one time a day for depression. 1/15/2025 Seroquel Oral Tablet 100…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-20 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to obtain consent for psychotropic medication for 1 of 3 (R5) residents reviewed for unneccessary medication in a sample of 15. Findings include: R5's Care Plan, dated 10/21/2023, documents PSYCHOTROPIC MEDS: (R5) requires the use of psychotropic medication, Risperidone to assist with managing mood and behavior related to DX (diagnosis) Huntington Disease; anxiety and metabolic encephalopathy. ANXIETY MEDS: (R5) requires the use of anxiety medication, Clonazepam and Ativan to assist with managing anxiety related to DX Huntington Disease; anxiety and metabolic encephalopathy. DEPRESSION MEDS: (R5) requires the use of depression medication, Fluoxetine and Mirtazapine to assist with managing depression related to DX Huntington Disease; anxiety and metabolic encephalopathy. R5's admission Record, not dated, lists Huntington's Disease as diagnosis. R5's Physician Order Sheet (POS), dated 11/09/24, documents Fluoxetine HCl Oral Tablet 20 MG (Fluoxetine HCl) Give 1 tablet by mouth one time a day for depression. 1/15/2025 Seroquel…

  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 · E2025-01-13 · tag F0712 — pattern
  Ensure that the resident and his/her doctor meet face-to-face at all required visits.
  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 record review and interviews, the facility failed to ensure physician visits were alternated with the Nurse Practitioner visits every 60 days after the first 90 days of admission for 4 of 4 residents (R1, R2, R6 and R7) reviewed for physicians' visits in the sample of 8. Findings include: 1.R1's Face Sheet, dated 12/31/24, documented R1 was admitted to the facility on [DATE] with diagnoses of hemiplegia, diabetes, weakness, gastroesophageal reflux disease (GERD), convulsions, depression, hemiplegia, cardiomyopathy, hypertension, and congestive heart failure. R1's Minimum Data Set, dated [DATE], documented R1 is cognitively alert. He uses a wheelchair for mobility due to right sided weakness. R1's Care Plan, dated 12/26/24, documented R1 is a bleeding risk, he has a self-care deficit with activities of daily living (ADLS), diabetic risk, seizure risk, skin complication risk, altered communication, heart failure risk, and fall risk. R1's electronic medical record (EMR) documented he was seen by the nurse…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-13 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin and allegations of abuse to the Administrator and Illinois Department of Public Health for 2 of 4 residents (R2, R8) reviewed for abuse in a sample of 8. Findings include: 1. R2's Face Sheet documented R2 was admitted to the facility on [DATE], with diagnoses of metabolic encephalopathy, severe protein-calories malnutrition, diabetes, dysphagia, dementia, schizoaffective bipolar disorder, wedge compression fracture of the third lumbar vertebra, severe intellectual disabilities, hyperlipidemia, rheumatoid arthritis, heart failure, osteoporosis, Down syndrome, vascular dementia, and gastroesophageal reflux disease. R2's Minimum Data Set, MDS, dated [DATE], documented R2 is severely cognitively impaired with minimal hearing deficit. She requires substantial assistance with eating and is dependent on staff for all other activities of daily living, (ADL's). R2's Care Plan, dated 12/21/24, documented R2 is at risk for abuse…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  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 investigate allegations of verbal abuse and injury of unknown origin for one of 4 residents (R2) reviewed for investigation of abuse in the sample of 8. Findings include: R2's Face Sheet, undated, documents R2 has diagnoses of diagnoses of metabolic encephalopathy, severe protein-calories malnutrition, dementia, schizoaffective bipolar disorder, severe intellectual disabilities, Down syndrome, and vascular dementia. R2's Minimum Data Set (MDS), dated [DATE], documents resident is severely cognitively impaired with minimal hearing deficit. R2's MDS documents she requires substantial assistance with eating and is dependent on staff for all other activities of daily living (ADL's). R2's Progress noted, dated 10/2/24 at 10:23 AM, documents V20, Licensed Practical Nurse, LPN, was notified by V17, CNA, that while performing morning care, she noticed a 3x3cemtmeter (cm) bruise on R2's left upper arm. V17 notified V20 who evaluated the bruise of unknown…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-10-25 · tag F0800 — widespread
  Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and observation, the facility failed to provide the required amount of protein to serve the residents. This has the potential to affect all residents in the facility. Findings Include: The facility recipe for Oven Herb Roasted Turkey Breast documents, slices 2.5 ounces of weighed portions. Serve 2.5 ounces of weighed portions to provide 2 ounces protein serving. Use scale to weigh and portion accurately. The facility was not observed initially utilizing a scale to weigh the turkey portions. V21, District Manager, stated, It's about one slice per person. On 10/22/24 at 12:00 PM, the kitchen was serving oven herb roasted turkey, with the portions appearing small. On 10/22/24 at 12:05 PM, V21, District Manager, brought out the scale. The oven roasted turkey breast portion was weighed and it was only 2 ounces. They continued to serve out the 2 ounces of oven sliced turkey, which was one slice of turkey meat. The kitchen then ran out of the oven sliced turkey and had to offer a substitute. On 10/23/24 at 12:00 PM, V12, Dietary Manager, stated, I don't…

  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

$338,854 in federal fines across 6 penalties. 1 Medicare payment denial on record.

• $38,715 — penalty dated 2026-04-30
• $24,421 — penalty dated 2025-07-08
• $21,255 — penalty dated 2025-04-24
• $220,695 — penalty dated 2024-12-18
• $22,588 — penalty dated 2024-08-14
• $11,180 — penalty dated 2023-12-14
• Medicare payment denial — starting 2025-01-18 for 2 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

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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 $455K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in IL