Hawthorne Inn Of Danville
3222 Independence Drive, Danville, IL 61832 · For profit - Corporation · 80 certified beds · (217) 431-1600 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- 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
- it has 1 actual-harm citation
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 improved from 3 to 4 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 | 28.1% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.2% | 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 | 10.1% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 5.4% | 54.2% | 6.5% | better 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 | 6.8% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.1% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 22.1% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.3% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.7% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.7% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.5% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.5% | 2.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 92.0% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.2% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 20.6% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.61 | 2.02 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.19 | 2.22 | 1.80 | worse |
‡ 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.
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.
59.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 187 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 94 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 48% 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.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.8%CMS range 52.5–65.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.2%CMS range 10.3–18.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 56.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 54.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 44.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 99.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 77.1% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 73.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 4.3–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 80 beds and averages 74.3 residents a day — about 93% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.98 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.43 hrs/resident/day on weekends vs 4.20 on weekdays — 18% thinner on weekends. RN hours go from 1.13 to 0.72 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · G2025-05-01 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 effectively manage pain, assess for pain, and report pain to the provider for two of three residents (R167, R169) reviewed for pain in the sample list of 28. This failure resulted in R167 experiencing severe pain as evidenced by facial grimacing, missed therapy sessions, and affecting activities of daily living. Findings include: The facility's Pain Management policy, dated 3/3/22, documents the following: Residents will be assessed for pain on admission, quarterly and with any significant change in condition. Residents will be assessed for pain every shift and notify the physician, if needed, regarding pain or pain indicators. Residents will be monitored until pain is resolved/controlled and periodically thereafter. Document pain and the resident's response to medication or treatment. 1.) R167's Hospital Note, dated 4/15/25, documents R167 has right side spasticity, especially to right leg, that is bothersome to R167. Baclofen (muscle relaxant) 5 milligram (mg) daily was started on 4/14/25, and R167 seemed…
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 · D2025-08-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 prevent cross contamination during wound care and implement pressure ulcer treatments for one of four residents (R4) reviewed for wounds in the sample list of eight. Findings Include: The facility's Wound Care policy, dated 10/16/24, documents wounds are subject to infection, and to wash your hands and wear gloves as part of wound care. This policy documents follow physician's orders for wound care and enter physician's orders into the resident's electronic medical record (EMR). R4's Hospital Discharge Transfer Orders, dated 7/31/25, document R4 has an unstageable pressure ulcer of the coccyx and a deep tissue injury to the right heel. R4's active care plan documents R4 admitted to the facility on [DATE], and includes an intervention for wound treatments and dressing changes per physician's order. R4's Initial Wound Evaluation & Management Summary, dated 8/5/25, recorded by V30, Wound Physician, documents R4's stage two pressure ulcer 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 before2025-08-13 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 medical records are complete and accurate for one of four residents (R1) reviewed for injuries in the sample list of eight. Findings Include:R1's Nursing Notes document R1 admitted to the facility from the hospital on 7/10/25. R1's Nursing Notes, dated 7/10/25, do not document an assessment of R1's skin or if R1 had any skin issues or bruising. R1's Nursing Note, dated 7/13/25 at 3:39 PM, documents R1's incisions to left thigh, right groin, and chest are closed. There is no documentation in R1's nursing notes between 7/10/25 and 7/16/25 that R1 had any bruising. R1's admission Observation, dated 7/10/25, documents there were no alterations in R1's skin. R1's Skin Assessment, dated 7/16/25, documents, Incisions & bruising. No new areas of concern. This assessment does not document the location of R1's bruising. On 8/13/25 at 8:31 AM, V10, Registered Nurse, stated R1 admitted to the facility five weeks post Coronary Artery Bypass Grafting (CABG).…
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 · D2025-06-17 · tag F0635 — isolatedProvide doctor's orders for the resident's immediate care at the time the resident was admitted.
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 interview, the facility failed on admission to obtain complete physician orders for medication to meet the immediate needs of a resident. This failure affected one (R1) of eight resident reviewed for medications on the sample list of 12. Findings include: R1's current Continuity of Care sheet documents R1 diagnoses Problem list as follows: Paroxysmal Atrial Fibrillation, Unspecified Atrial Flutter, Cardiac Murmur, Unspecified, Essential (primary) Hypertension, Alzheimer's Disease, Unspecified, Vitamin D deficiency, Unspecified, Ascorbic Acid Deficiency, and Vitamin Deficiency, Unspecified. R1's Local Hospital Discharge - Cardioversion Procedure Note, dated 5/12/25, documents R1 had Atrial Flutter (fast heart rate) with rapid ventricular rate of the heart while in the hospital. The rapid heart rate required Electro-Cardioversion (electric shock treatment to the heart) with sedation to convert R1's heart rate to normal sinus rhythm. R1's Local Hospital Discharge Medication List, dated…
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 before2025-06-17 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility pharmacy repeatedly failed to provide medications in a timely manner. This failure affects one (R1) of eight residents reviewed for medications on the sample list of 12. Findings include: R1's Local Hospital Discharge Medication List, dated 5/13/25, documents the following incomplete physician orders for Fosinopril, Metoprolol Succinate, and Mirtazapine as follows: 1. Fosinopril (Medication for the treatment for high blood pressure and heart failure) for 10 MG Tabs. Commonly known as: Monopril. The Fosinopril order documents See instructions. There are no instructions documented in the discharge orders that include dosage, route, or time medication was to be administered. R1's current Physician Order Report Sheet (POS) documents R1 was admitted to the facility on [DATE] at 12:40 pm. R1's Physician Order for Fosinopril , was clarified and ordered by V8, Nurse Practitioner, as follows: Fosinopril tablet; 10 mg; amt: 10; oral [DX: Essential (primary) hypertension],…
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 · D2025-06-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 interview, the facility failed to prevent significant medication errors by failing to clarify incomplete hospital physician ordered medications on admission in a timely manner, and failed to obtain medication from the pharmacy in a timely manner. These failures resulted in multiple missed doses of heart and blood pressure medication administration after electro-cardioversion, and missed doses of antidepressant/appetite stimulant medications. This failure affects one (R1) of eight residents reviewed for medications on the sample list of 12. Findings include: R1's Hospital Record CARDIOVERSION PROCEDURE NOTE (NON-OR) documents: Procedure Date: 5/12/2025, Pre-Procedure Diagnosis/Indication for Procedure: Atrial flutter with rapid ventricular rate. Post-Procedure Diagnosis: Sinus rhythm. Procedure: Electro-cardioversion with sedation. R1's current Continuity of Care sheet documents R1 diagnoses Problem list as follows: Paroxysmal Atrial Fibrillation, Unspecified Atrial Flutter, Cardiac…
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 before2025-06-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 maintain complete and accurate medical records for one (R1) of twelve resident reviewed medical record accuracy on the sample list of 12. Findings include: 1.) R1's admission Observations, dated [DATE], documents R1's code status was Full Code (attempt resuscitation). R1's Face Sheet, dated [DATE] - [DATE], documents R1's code status was Full Code. R1's IDPH (Illinois Department of Public Health) Practitioner Order For Life-Sustaining Treatment (POLST) Form, also dated [DATE], signed by R1, documents R1's code status was No CPR (Cardio Pulmonary Resuscitation), Do Not Attempt Resuscitation (DNAR). R1's Physician Order Sheet (POS), dated [DATE] - [DATE], documents R1's code status was a Full Code, and incongruent with the above POLST signed by R1 on [DATE]. R1's Progress Notes, dated [DATE] at 11:04 am, documents the following; Patient (R1) did c/o (complain/of) not feeling well, c/o SOB (complained of shortness of breath), weakness, cough. Heard…
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 before2025-05-01 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were available to be given as ordered for four of five residents (R167, R168, R169, R171) reviewed for new admissions in the sample list of 28. Findings include: The facility's Medication Administration policy, dated February 2004, documents the objective of the policy is to provide the residents with medications as deemed necessary by the physician. This policy documents to accurately transcribe physician orders to the Medication Administration Record (MAR) and administer medications as ordered. The facility's Pharmaceutical Procedure, dated 1/5/23, documents convenience drug boxes may be kept by the facility and used to obtain starter or first doses of medications, and normal ordering procedures should be followed to ensure the resident receives a full supply of the ordered medication. This procedure documents to notify the pharmacy of new orders and when medications are removed from the convenience box, so that a replacement can…
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 before2025-05-01 · tag F0881 — failed to use antibiotics responsibly — patternImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to implement antibiotic stewardship by failing to ensure symptoms meet urinary tract infection (UTI) criteria and obtain/review urine cultures for four of six residents (R18, R19, R48 R52) reviewed for antibiotic stewardship in the sample list of 28. Findings include: The facility's Antibiotic Stewardship policy, dated 12/18/19, documents the purpose of the policy is to reduce the inappropriate use of antibiotics, improve resident outcomes, and reduce adverse events. This policy documents the facility uses McGreer Criteria as part of its Infection Control Program and the facility will track antibiotic use daily. The Revised McGreer Criteria for Infection Surveillance Checklist, dated 11/5/24, documents for UTIs without indwelling urinary catheters surveillance definition: Must fulfill both 1 AND 2. 1. At least one of the following sign or symptom Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and one or more of the following: Acute costovertebral angle pain or…
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 · D2025-05-01 · 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 observation, interview, and record review, the facility failed to prevent a fall by failing to utilize a blind spot mirror before opening a door for one (R58) of three residents reviewed for falls on the sample list of 28. Findings Include: R58's electronic health record documents R58 was admitted to the facility on [DATE] for skilled nursing and rehab. On 4/28/2025 at 10:05 AM, R58 was observed walking back and forth down the halls and around the memory care unit with R58's four wheeled walker. R58's fall investigation report, dated 4/11/2025, documents R58 had a fall at 4:59 PM. This report documents R58 was ambulating in the hallway on the memory lane unit close to the front door, when V12 (Dietary Aide) opened the door, bumping R58. R58 lost her balance and fell. This report also documents V13 (Certified Nursing Assistant) witnessed the fall. On 4/29/25 at 10:47 AM, V5 (Registered Nurse) stated R58 fell on 4/11/2025 when V12 went through the double doors hitting R58, who was standing on the other…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-04-17 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
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 employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 74 residents in the facility. Findings include: On 4/15/2024 at 10:28AM, V16 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V16 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V16 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V16 reported the facility dietician only provides services for the facility one day per month. At this time, V16 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic and nutrition school or program authorized by…
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 11 citations
- Potential for harm · F2024-04-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to prevent direct cross-contamination of stored food and ice, failed to date and label TCS (time/temperature control for safety) food, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food storage equipment. These failures have the potential to affect all 74 residents residing in the facility. Findings include: 1. On 4/15/2024 at 10:43AM, the kitchen walk-in freezer evaporator cooling unit was leaking condensate into a plastic bin located below the cooling unit on a wire storage shelf. The leak resulted in large accumulations of ice forming inside of the bin and overflowing onto shelving beneath the bin. Numerous boxes of food items were stored directly beneath the leaking cooling unit. A fully-opened cardboard box of cookies was stored immediately below the overflowing bin, directly exposing the cookies to the leaked condensate. Frozen condensate drips were present on the box interior. On 4/17/2024 at 11:14AM, V16 (Dietary Manager) observed the above leak…
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 · E2024-04-17 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
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 timely complete Minimum Data Set (MDS) assessments for four (R4, R44, R49, R58) of 18 residents reviewed for MDS assessments in the sample list of 36. Findings include: The facility's MDS Completion policy dated 6/1/22 documents quarterly MDS assessments will be completed at least every three months and the MDS Coordinator is responsible for ensuring completion of the required MDS assessments and will transmit MDS assessments at least weekly. R49's MDS dated [DATE], R4's MDS dated [DATE], R44's MDS dated [DATE] and R58's MDS dated [DATE] document these Quarterly MDS assessments are in process and have not been completed. R49's MDS dated [DATE] was the last completed MDS documented in R49's electronic medical record (EMR). R4's MDS dated [DATE] was the last completed MDS documented in R4's EMR. R44's MDS dated [DATE] was the last completed MDS documented in R44's EMR. R58's MDS dated [DATE] was the last completed MDS documented in R58's EMR. On 4/16/24…
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 · D2024-04-17 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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 timely transmit a Minimum Data Set (MDS) assessment for one (R35) of 18 residents reviewed for MDS assessments in the sample list of 36. Findings include: The facility's MDS Completion policy dated 6/1/22 documents the MDS Coordinator will ensure completion of the MDS assessments and will transmit MDS assessments at least weekly. This policy documents comprehensive assessments will be transmitted within 14 days of the Care Plan completion date; and Prospective Payment System and Quarterly assessments will be transmitted within 14 days of the completion date. R35's electronic medical record MDS listing documents R35's Annual MDS dated [DATE] was completed, but not submitted. On 4/16/24 at 11:26 AM V10 MDS/Care Plan Coordinator stated R35's January 2024 MDS has not been submitted yet since V10 was not familiar with how to complete the CAA (Care Area Assessment) section of the MDS. V10 stated there is a 14 day window to complete annual MDS assessments. V10…
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 before2024-04-17 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 received the recommended/ordered amount of Enteral feeding for two of two residents (R53, R11) reviewed for Enteral feedings in the sample list of 36. Findings include: The facility's Tube Feeding (G and N/G) (Gastrostomy and Nasogastric) policy with a revised date of 3/3/22 documents, Objectives: 1. To maintain the desired nutritional and fluid status of a resident. Procedure: 1. M.D. (Medical Doctor) will order type of feeding supplement, duration/rate of feeding, frequency, and amounts of flushing. Order must include caloric content, as well as volume. Documentation: 1. Date/time of feeding. 2. What was administered, flow rate, and duration of feeding. 3. Any complications or new occurrences before, during, or after procedure. 4. Licensed staff completing the procedure. 5. Maintain accurate documentation of Intake and Output for every shift and for every 24 hours. 1.) R53's Care Plan dated 2/23/24 documents diagnoses…
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 · D2024-04-17 · 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
Based on observation, interview and record review the facility failed to obtain Physician's Orders for oxygen administration and failed to care plan for the use of oxygen for one of two residents (R32) reviewed for oxygen use in the sample list of 36. Findings include: The facility's Oxygen Therapy & (and) Safety policy with a revised date of 4/9/20 documents, Purpose: To provide a source of oxygen to persons experiencing an insufficient supply of same and to address the use and storage of oxygen and oxygen equipment. Oxygen Therapy a. M.D. (Medical Doctor) order will provide: when to use, how often, liter flow, and whether to use cannula or mask. Address use of oxygen in Care Plan. R32's Physician Order Report dated 3/16/24 through 4/16/24 documents diagnoses including Alzheimer's Disease with Late Onset, Anxiety Disorder, Acute Upper Respiratory Infection, Cough and Wheezing. This Order Report documents an order to change oxygen tubing and humidification bottle every week but there is no order for the oxygen administration, and no order to designate the amount of liter flow or 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 · D2024-04-17 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 accurately and routinely assess side rail use per the facility's policy, obtain consent for side rail use, document alternative interventions attempted prior to use, and care plan for side rails for two (R9, R59) of two residents reviewed for siderails in the sample list of 36. Findings include: The facility's Side Rails policy dated 11/28/17 documents: It is the policy of the facility to ensure that side rails are not used unless an assessment to determine risk has been completed and it is determined that the side rails do not pose a danger to the resident. The facility will use appropriate alternatives prior to installing a side or bed rail. An assessment will be completed by licensed staff prior to the use of side rails. If the resident is assessed and it is determined that the resident would benefit from the use of side rails to promote independence, reassessment will occur at least every 90 days. Risk of benefits of side rail use 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.
- Potential for harm · D2024-04-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 complete quarterly psychotropic mediation assessments, failed to identify/document/care plan specific targeted behaviors and nonpharmacological interventions, failed to include a duration for a PRN (as needed) psychotropic medication order, failed to failed to obtain/document consent for psychotropic medication use, and failed to rule out underlying causes of behaviors prior to initiating psychotropic medications for three (R58, R78, R36) of five residents reviewed for unnecessary medications in the sample list of 36. Findings include: The facility's Psychopharmacologic Drug Usage Procedure dated 10/18/17 documents psychotropic medication use will be evaluated initially and at least every 90 days and include the rationale for continuing the medication. This policy documents PRN psychotropic medications will be limited to 14 days unless otherwise ordered by the physician with a documented rationale to extend beyond the 14 day timeframe, and the duration…
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 before2024-04-17 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 a culture to ensure that the appropriate antibiotic was being used for one (R8) of two residents reviewed for antibiotic stewardship from a total sample list of 36 residents. Findings include: The facility Antibiotic Stewardship Policy dated 12/18/19 documents that it is the policy of the facility to follow an antibiotic stewardship program and to reduce the inappropriate use of antibiotics. R8's progress notes dated 2/28/24 at 10:03AM, document that R8 has a history of urinary tract infections and that she is sleeping more than usual. R8's progress notes dated 2/28/24 at 12:27PM, document that a urine dip test was performed. On 2/29/24 at 4:40AM, labs were drawn, and fluids were encouraged, but neither a urinalysis nor a culture and sensitivity of the urine was ordered or sent for testing. On 2/29/24 at 12:02PM, Cipro (antibiotic) 500 milligrams was ordered to be administered twice daily for ten days. On 3/16/24 at 2:56PM, V2 Director of Nursing stated that a culture should have been done to ensure that the correct…
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 · D2024-04-17 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 offer and administer pneumonia vaccine as recommended for residents. These failures affect two of five residents (R21, R48) reviewed for vaccinations in the sample list of 36. Findings include: The facility's Pneumococcal Vaccination policy with a revised date of 8/11/22, Policy: It is the policy of the facility to provide immunizations in accordance with CDC (Centers for Disease Control) recommendations. Procedure: All residents aged 65 years or more and those residents that are determined to be at high risk (those with chronic illness such as lung, heart, or kidney disease, sickle cell anemia, diabetes, recovering from acute illness, those in congregate living environments, with a weakened immune system, etc.{etcetera}) will be offered the Pneumococcal vaccine as recommended by the CDC. 1. All residents will have their immunization status assessed at the time of admission and annually thereafter. Any vaccination that have been received prior 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 · D2023-03-23 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview, the facility failed to ensure that a resident was afforded privacy during G-Tube (Gastrostomy Tube) medication administration. This failure affected one (R50) of 26 residents reviewed for privacy of the sample list of 26. Findings include: R50's Physician Order Summary (POS) dated 2/22/23- 3/22/23, documents the following diagnoses: Personal history of traumatic brain injury, Gastrostomy status, Aphasia, Spastic hemiplegia affecting right dominant side, Encephalopathy, unspecified-static, and Dysphagia, unspecified. On 3/21/23 at 3:10 pm R50 was lying in bed. R50 did not respond verbally. V11, Licensed Practical Nurse (LPN) and V3, Assistant Director of Nursing (ADON) entered R50's room, leaving R50's privacy curtain and window curtain fully open. R50's roommate, R31 was seated in R31's wheelchair, two feet away from the left side of R50's bed. V11, LPN pulled back R50's blanket. R50's bare abdomen and Gastrostomy feeding tube were in full view of R50's roommate, R31. V11, administered R50's Baclofen and Senna 8.6 mg crushed 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 before2023-03-23 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, observation and interview the facility failed to provide safe Gastrostomy tube (tube surgically inserted into the stomach through the abdomen) administration of medication according to standard of practice and physician order. This failure affected one of one resident (R50) reviewed for Gastrostomy tube medication administration on sample of 26. Findings include: R50's Physician Order Summary (POS) dated 2/22/23- 3/22/23, documents the following diagnoses: Personal history of traumatic brain injury, Gastrostomy status, Aphasia, Iron deficiency anemia, unspecified, Vitamin deficiency, unspecified, Epilepsy, unspecified, not intractable, without status epilepticus, Spastic hemiplegia affecting right dominant side, Encephalopathy, unspecified-static, Gastro-esophageal reflux disease without esophagitis, unspecified, Other muscle spasm, Nausea with vomiting, unspecified, and Dysphagia, unspecified. The same POS documents: Diet: NPO (nothing by mouth) with g-tube (Gastrostomy tube) feedings.…
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.
“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.
Part of a chain
This home belongs to RESIDENTIAL ALTERNATIVES OF ILLINOIS — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 3.3 | +0.7 vs chain |
| Staffing | 3 of 5 | 3.1 | -0.1 vs chain |
| Quality measures | 2 of 5 | 2.1 | -0.1 vs chain |
The other 6 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MILLER, LISA | Individual | W-2 MANAGING EMPLOYEE | since 05/07/2010 |
| KEMPINERS, WILLIAM | Individual | CORPORATE DIRECTOR | since 05/07/2010 |
| KNIERY, JOHN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 09/05/2018 |
| MCMAHAN, BENJAMIN | Individual | CORPORATE DIRECTOR | since 09/05/2018 |
| SHAW, JEFFREY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 05/07/2010 |
| WILSON, RONALD | Individual | CORPORATE OFFICER | since 09/05/2018 |
| RESIDENTIAL ALTERNATIVES OF ILLINOIS INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 03/10/2022 |
CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $998K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. 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 146090. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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.