Crestwood Terrace

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.

Staffing

How full it usually is: this home is certified for 126 beds and averages 107.0 residents a day — about 85% occupied, or roughly 19 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the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026.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 2.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.39 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 1.95 hrs/resident/day on weekends vs 2.40 on weekdays — 19% thinner on weekends. RN hours go from 0.59 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 20% is below the national median of 45%.

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

Inspection trend

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

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.

29 citations, most serious first. The 18 most serious are shown; the remaining 11 are one tap away and print in full.

• Actual harm · Gcited before2025-12-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to follow their abuse policy and failed to protect one resident (R3) from both physical and sexual abuse by R2. This failure affected one (R3) of seven residents (R1, R2, R3, R4, R5, R6, and R7) reviewed for abuse. These failures resulted in R3 being physically and sexually assaulted by R2 and R3 also suffering psychosocial harm stating feelings of fear and nightmares. Findings include:R3's face sheet documents diagnose that include but are not limited to major depressive disorder and suicidal ideations.R3's Final Report titled, Final Investigation of Allegation of Abuse, dated 12/24/2025, documents, in part, R3 reported that on 12/20/25 she (R3) went into the shower room after breakfast to take a shower. Reportedly while in the shower R3 stated that she (R3) heard the door open and that she (R3) saw some shoes. R3 stated that she (R3) yelled get out I'm in here. R3 stated that the male co- resident R2 came into the shower and forced himself (R2) on her (R3). R3 stated that she (R3) yelled for help and another…

  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 before2025-07-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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 interview and record review, the facility failed to follow hospital orders for a fluid restriction after a resident (R1) was hospitalized for low sodium and failed to complete additional laboratory work for a resident's (R1) low sodium levels for one out of three residents reviewed for improper nursing care in a total sample of three. This failure resulted in R1 suffering a syncopal episode twice within four days and needing to be hospitalized each episode for low sodium and bradycardia. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, type 2 diabetes, schizoaffective disorder, bradycardia, and syncope/collapse.R1 no longer resides in the facility. A Nursing note dated 5/ 31/ 25 document R1 was found lying on the floor in R1's room. The fall was unwitnessed. Vital signs were within normal limits except the heart rate. The heart rate was 49 (normal heart rate is 60-100 beats per minute). R1 was not able to stand. The doctor was called and ordered to send R1 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-03-23 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect a resident's right to be free from physical abuse (R2) from another resident with known history of aggressive behavior (R3) for one (R2) of five residents reviewed for abuse in a sample of eight. This failure resulted in R2 being physically assaulted and emergently transferred to the hospital for evaluation of facial trauma. Findings include: R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder, Bipolar Type; Malignant Neoplasm Of Skin; Morbid (Severe) Obesity Due To Excess Calories; Age-Related Nuclear Cataract, Bilateral; Hypermetropia, Bilateral; Presbyopia; Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms; Schizophrenia; And Chronic Viral Hepatitis C. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 14 indicating, indicating intact cognition. R2 is 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify a resident (R1) as a high fall risk after new onset shuffling of gait and failed to put interventions on the care plan in regards to the shuffling. This affected one of three residents (R1) reviewed for fall prevention interventions. This failure resulted in R1 getting up unassisted and falling causing a laceration to the forehead that needed repair at the hospital with three to four stitches. Findings include: R1 is a [AGE] year old with the following diagnosis: dementia, schizophrenia, and epilepsy. A Nursing note dated 8/16/24 at 6 AM documents the CNA reported to the nurse that R1 fell in R1's room. R1 stated that R1 lost R1's balance while trying to use the bathroom. R1 had a small laceration to the right forehead. The wound was cleaned and R1 was sent to the hospital via 911. An admission Summary note dated 8/16/24 documents R1 returned from the hospital with 3 to 4 stitches noted and facial bruising. The Hospital After Visit Summary…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide effective supervision to monitor and intervene before a resident-to-resident verbal altercation escalate into an avoidable physical altercation. This affected two of four residents reviewed for supervision and monitoring. This failure resulted in R1 and R2 having a verbal disagreement, escalating into a physical altercation, resulting in R1 observed with bleeding at back of head. R1 was sent to hospital with diagnosis of subdural hematoma and facial contusions. Findings include: R1 face sheet shows R1 has diagnosis of mild intellectual disabilities, disruptive mood dysregulation disorder, impulsive disorder and schizophrenia. R1's quarterly MDS assessment dated [DATE] section C for cognitive pattern denotes a score of 8 (cognitive impairments), section E for behavior, potential indicators of psychosis denote hallucinations and delusions. Zero (behavior not exhibited) is noted for physical behavioral symptoms directed towards others and zero…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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 interview and record review, the facility failed to ensure a lab draw for an antiseizure medication was completed as ordered for two residents (R1, R2) out of three reviewed for physician orders in a total sample of five. This failure resulted in R2 suffering a seizure and being sent to the hospital where the antiseizure medication level was low. Findings Include: R2 is a [AGE] year old with the following diagnosis: idiopathic epilepsy and paranoid schizophrenia. On 3/13/24 at 12:00PM, R2 was unable to remember when R2 went to the hospital last, but reported it was due to having a seizure while at the facility. R2 stated R2 was born with seizures and R2 has to take medications to control them. R2 was not aware of any missed blood draws. R2 does not remember the last time R2's blood was drawn at the facility. R2 was unaware if any seizure medication levels were low. On 3/14/24 at 11:29AM, V10 (Nurse) was not able to remember a date but stated one day R2 was not responding and staring off while sitting in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by other residents. This failure applied to four of four (R1, R2, R3, and R4) residents reviewed for abuse and resulted in R3 sustaining a nosebleed after being punched by R4 and resulted in R2 sustaining a closed fracture of the right ankle, which required a surgical procedure, after being involved in a physical altercation with R1. Findings include: R2 is a [AGE] year-old male who was admitted to the facility on [DATE], past medical history includes, but not limited to schizoaffective disorder bipolar type, bacterial infection unspecified, Epilepsy, unspecified fracture of right lower leg subsequent encounter for closed fracture with routine healing, conversion disorder with seizure or convulsion, etc. On 11/17/2023 at 11:35AM, R2 was observed sitting in the dining area, alert and oriented and stated that he just returned from an orthopedic appointment, they removed the staples from his leg.…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provided a resident (R1) with proper footwear to prevent or reduce the risk of a fall incident. This affected one of three residents (R1) reviewed for fall prevention interventions. This failure resulted in R1 falling in the hallway and sustaining a fracture to the right arm. Findings Include: R1 is a [AGE] year old with the following diagnosis: paranoid schizophrenia, alcohol abuse, and fracture of shaft of right humerus. On 8/9/23 11:53AM, R1 was interviewed. When asked why R1's arm was in a sling R1 stated R1 fell to the floor and broke R1's arm. R1 endorsed being sent to the hospital after that. R1 was not able to give any other details what happened after the fall. R1 then endorsed that 2 other staff were present but was not able to give any names. R1 endorsed staff gave R1 a pair of shoes without any laces when R1 returned to the facility. On 8/9/23 at 12:39PM, V2 (Nurse) stated that V3 (CNA) and V4 (Manager on Duty/Director of Housekeeping) said…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-01-09 · 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

  Based on interview and record review, the facility failed to supervise a resident who was diagnosed with bilateral eye blindness, used a white cane and required supervision and touching assistance with ambulation to prevent an avoidable accident and altercation. This affected two of three residents (R1, R2) reviewed for supervision. This resulted in R1 tripping over R2's wheelchair and the resident engaging in a resident-to-resident altercateion.Findings Include:R1 was diagnosis with category five blindness to the right eye, category four blindness to the left eye, atrophy of globe of right eye. Minimal Data Set Section B (vision) document severely impaired. Section C (cognitive pattern) dated 12/29/25 documents: brief interview for mental status summary score of fifteen which indicate cognitively intact. Section GG (functional abilities) documents mobility device: cane/crutch. Walk ten (10) feet: Once standing, the ability to walk at least 10 feet in a room, corridor or similar space documents a score of (04) four. 04 indicates: supervision or touching assistance- helper provides…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow their abuse policy and procedures by restricting a resident from returning to their room with their personal items and physically restraining them against their will. This failure applies to one of three residents (R1) reviewed for abuse. Findings include: R1 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Recurrent Severe Major Depressive Order with Psychotic Symptoms, PTSD, Generalized Anxiety Disorder, Brain Cancer, and Suicidal Ideations who was admitted to the facility 01/14/2025. On 03/31/2025 at 1:00 PM V3 (Psychosocial Services Rehabilitation Services Assistant/Security Guard) stated on 03/19/2025 between approximately 7:15 AM and 7:20 AM during smoke break, he heard social services being paged to the front desk and when he arrived R1 was in the middle of screaming, yelling, and cursing at V5 (Receptionist) and stating no one could check his things and they didn't have a right to check his belongings. V3…

  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 before2024-12-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to prevent a physical altercation between a resident (R1) with a history of delusions, agitation, and aggressive behavior towards peers, and his roommate (R2) by failing to adequately monitor the two residents inside their room with the door closed, during lunchtime. This lack of supervision resulted in a failed opportunity to identify delusional and aggressive behavior from R1 that led to R1 hitting R2 in the head with his hands, grabbing him by the shirt, and pulling him out of his room. Findings include: R1 is a [AGE] year-old former resident of the facility with diagnosis listed in part, but not limited to, schizoaffective disorder, schizophrenia, suicidal ideations, alcohol abuse, and cannabis abuse. On 12/09/2024 at 10:52 AM, V1 (Administrator) said on 10/20/2024, R1 had an altercation with his roommate, R2. V1 said R2 wanted to use their bathroom, but R1 had placed a sheet on the floor in front of the entrance to the bathroom. V1 said R1 told R2…

  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 · D2024-10-31 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to follow their policy and procedures for developing a comprehensive care plan by not updating care plan interventions as needed and not implementing personalized and effective care plan interventions for a resident exhibiting a pattern of increasing anxiety, agitation, and verbal and physical aggression. This failure applies to one of four residents (R4) reviewed for care planning. Findings include: R4 is a [AGE] year-old male with a diagnoses history of Schizoaffective Disorder, Schizophrenia, Suicidal Ideations, Cannabis Abuse, and Alcohol Abuse who was admitted to the facility 03/28/2024 and discharged from the facility against medical advice 10/21/2024. R4's progress note dated 4/9/2024 documents he was observed with loud speech in dining area and came to the nurse's station to asking to be given something to calm him down because he was very anxious and was given a Sedative as prescribed. R4's progress note dated 4/21/2024 documents he was involved…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-10-10 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  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 an employee from engaging in verbal abuse with a resident and failed to follow their abuse policy of immediately reporting abuse to the abuse coordinator. This failure affects two (R4 and R5) of four residents reviewed for verbal abuse and has the potential to affect all 109 residents currently in the facility. Findings include: Facility provided Census upon entrance that documents 109 residents currently in the building. R4 is [AGE] years old, has been residing in the facility since 8/22/13. R4 has diagnoses that include but are not limited to schizoaffective disorder. According to the electronic health record, R4 is alert oriented and does not have any documented cognitive deficits. R5 is [AGE] years old and was recently readmitted to the facility 8/15/24 with diagnoses that include schizoaffective disorder bipolar type. An interview was attempted with R5 during this investigation, however R5 refused to interact with the surveyor. R4 was…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-10 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to address the pharmacist recommendation for a gradual dose reduction of anti-depressant medication and failed to ensure the pharmacist recommendations were readily available to review in the resident's electronic health record. This failure applied to one (R1) of three residents reviewed for unnecessary medications. Findings include: R1 is [AGE] years old and admitted to the facility 5/15/23 with diagnoses that include but are not limited to Schizoaffective disorder, Major Depressive Disorder, Bipolar Disorder and Epilepsy. R1 transferred from the facility on 5/20/24 as a Resident initiated discharge. On 10/7/24 at 1:04PM R1 was interviewed and said they believed the facility was overdosing R1 with medications while living in the facility. The monthly Medication Regiment Review (MRR) conducted by V4 Pharmacy Consultant 2/20/24 was not located in the electronic health record, however, was available on request. The report for R1 on this day recommended 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-08-23 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  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 update care plan of residents with COVID infection. This deficiency affects all six (R1, R14, R16, R53, R54 and R89) residents in the sample of 23 reviewed for Care plan revision. Findings include: On 8/20/24 at 7:55AM to 9:23AM, Rounds made to the units with V20 Infection Preventionist and V8 PRSD ( Psych Rehab Service Director). Observed R1, R14, R16, R53, R54 and R89 were on droplet precaution due to COVID infection. Review medical records of R1, R14, R16, R53, R54 and R89. No care plan intervention developed for all residents with COVID infections. R89 tested positive for COVID infection on 8/12/24 while R1, R14, R16, R53 and R54 acquired on 8/13/24. On 8/20/24 at 10:18AM, Informed V20 Infection Preventionist that all six (R1, R14, R16, R53 and R54) residents did not have care plan developed for COVID infection. On 8/20/24 at 10:27AM, V2 DON (Director of Nursing) said that MDS (Resident Assessment) Care plan coordinator updates the care plan. Care plan is updated when there are changes in resident…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-23 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation interview and record review the facility failed to implement infection control protocol for resident with COVID infection and implementation of COVID surveillance in the facility. This deficiency affects all ten (R1, R6, R14, R16, R41, R50, R53, R54, R89 and R103) residents in the sample of 23 reviewed for Infection Control Prevention Program. Findings include: On 8/20/24 at 7:55AM, Rounds made to D unit with V20 Infection Preventionist (IP). Observed R14, R53, R54 and R1 were on droplet precaution due to COVID infection. V20 went inside of these rooms to check for isolation bin without wearing gloves, gown, and facial shield. On 8/20/24 at 8:20AM, V20 Infection Preventionist said that staff should wear N95 mask, face shield, mask and gloves when entering the room of resident with COVID (+). V20 said that they should have red plastic bag inside the isolation room. On 8/20/24 at 8:53AM, Rounds made to B and E units with V8 PRSD (Psych Rehab Service Director). Observed R89 and R16 were on droplet precaution due to COVID infection. Review medical records of R1,…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-23 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to follow their policy in notifying the residents' family when the resident was sent out to the hospital. This failure affected one (R63) of four residents in the sample of 23 reviewed for discharge. Findings include: On 3/16/2024, R63 was sent out to the hospital. Review of R63 nurses note did not show any documentation as to the residents' transfer to the hospital. On 8/22/2024 at 1:00 PM, V29 (RN) said that when a resident is sent out to the hospital after receiving the order from the doctor, the nurse is supposed to notify the administrator, and the residents' family. On 8/21/2024 at 12:54 PM, V25 (Assistance Director of Nursing) said that when the nurses send a resident out to the hospital, the nurse is expected to notify the administrator, director of nursing, and residents' family. On 8/22/2024 at 12:54 PM, V2 (Director of Nurses/DON) said that the nurses are expected to notify the administrator, DON, and the residents' families when residents are sent out to the hospital. Guidelines: Emergency transfers should occur…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-23 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 residents are free of any significant medication error. This deficiency affects 1 (R55) of 6 residents in a sample of 23 reviewed for medication administration. Findings include: On 8/20/2024 at 8AM during medication pass, V12 (Registered Nurse) stated R55 will be given scheduled Insulin medication later when morning tray is available. R55 ate breakfast in the room. Surveyor followed up multiple times regarding insulin administration. On 8/20/2024 at 11:25AM, Surveyor was informed by V12 that R55 morning scheduled insulin was not administered as ordered and recorded as a missed dose. V12 stated that insulin medication was not given to R55 because medication was not available in her medication cart. On 8/20/2024 at 11:33AM, V2 (Director of Nursing) stated medication should be given as scheduled per physician order. Medication Review Report: Diagnoses: Type 2 Diabetes Mellitus Without Complications Order Summary: Admelog Injection Solution 100Unit/ML (Insulin Lispro) Inject 10 unit subcutaneously 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.

  Pharmacy Service 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

No federal fines in the current CMS record. 1 Medicare payment denial on record.

• Medicare payment denial — starting 2024-12-06 for 80 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.

What families pay in IL