Dixon Rehab & Hcc

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 30.8% 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 39 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 0.25 therapist hours per resident per day in 2026Q1 — more than 36% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 32% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 97 beds and averages 71.7 residents a day — about 74% occupied, or roughly 25 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 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.03 hrs/resident/day on weekends vs 3.63 on weekdays — 16% thinner on weekends. RN hours go from 0.95 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% 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.

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.

21 citations, most serious first. The 16 most serious are shown; the remaining 5 are one tap away and print in full.

• Actual harm · Gcited before2025-01-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 interview and record review the facility failed to identify an area of pressure before becoming a stage 3, failed to have a wound evaluated by a wound care professional and failed to assess and document an area of skin breakdown. This applies to one of three residents (R1) reviewed for pressure in the sample of three. This failure resulted in R1 sustaining a stage 3 pressure ulcer with 90% slough and necrotic tissue to her sacrum. The findings include: The facility face sheet for R1 shows she was admitted to the facility on [DATE] with diagnoses to include spinal stenosis, Type 2 Diabetes Mellitus, abnormalities of gait and mobility and urge incontinence. The facility assessment dated [DATE] shows R1 to have severe cognitive impairment and requires maximal assistance with her activities of daily living. The same assessment shows R1 was admitted to the facility with a risk of developing a pressure injury but did not currently have any. The facility's electronic health record census tabs shows R1 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide 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 pressure injuries for residents at risk for pressure, failed to initiate treatment orders when pressure injury was found, failed to monitor a pressure injury for signs and symptoms of infection for 2 of 4 residents (R1, R3) for pressure in the sample of 4. This failure resulted in R1 developing a Stage 3 pressure injury to her right heel that became infected and R3 developing two Stage 2 pressure injuries to his sacrum. The findings include: 1. R1's Nursing admission data collection dated 10/3/24 shows R1 was admitted on [DATE] due to hysterectomy with bladder sling, no impaired skin integrity, abdominal area has 3 small incision sites. On 11/23/24 at 8:47 AM, R1 was sitting up in a wheelchair at the dining room table eating breakfast. R1 had heel protective boots on both feet and a mechanical lift sling underneath her. R1 said she was doing ok and had the boots on because her foot hurt her. On 11/23/24 at 9:20 AM, V3 Registered…

  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 before2024-10-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure effective fall interventions were in place for resident's safety who is a high risk for falls and has a history of falls. This failure resulted in R45 falling out of bed and sustaining a left hip fracture needing surgical repair for 1 of 18 residents (R45) reviewed for safety in the sample of 18. The findings include: R45's Physician Order Sheet show R45 is [AGE] year old with diagnoses of vascular dementia, hypertension, weakness and left hip fracture R45's facility assessment dated [DATE] show R45 is severely cognitively impaired (BIMS of 1) R45's fall risk assessment dated [DATE] show R45 as a high risk for falls. On 10/21/24 at 9AM, R45 was in bed moaning I am sore. V19 (Registered Nurse) was with R45 at this time and said R45 has a hip fracture due to fall. On 10/21/24 at PM, V20 (R45's daughter) said she was very disappointed at the facility. My mom has had four (4) falls. All of these falls were her trying to go 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 · G2024-10-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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 assess a residents weight loss and ensure nutritional interventions were implemented for a resident with significant weight loss. This failure resulted in R66's significant weight loss. This applies to 1 of 5 residents (R66) reviewed for weight loss in the sample of 18. The findings include: R66's face sheet shows he is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including muscle wasting, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below the knee, type 2 diabetes, peripheral vascular disease, and a non-pressure chronic leg ulcer of right lower extremity. R66's weight report provided on 10/22/24 documents: 8/27/24- 208.8 lb (pounds) 9/24/24- 184 lb 10/8/24- 186 lb 10/17/24- 182.2 lb R66's electronic health medical record documents Regular Diet, Regular Texture, Regular liquid Consistancy. Needs double portions of meat, eggs and milk at each meal for…

  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 · G2024-10-23 · tag F0697 — failed to manage pain — isolated
  Provide 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents pain was managed after undergoing hip surgery. This failure resulted in R45 experiencing severe pain to 1 of 18 residents (R45) reviewed for pain management in the sample of 18. The findings include: R45 has diagnoses that include fractured left hip undergoing hip surgery, dementia, hypertension and weakness. R45 was readmitted to the facility on [DATE] after undergoing surgical repair to her left hip fracture caused by a fall. On 10/21/24 at 9AM, R45 was in bed moaning I am sore. V19 (Registered Nurse/RN) was with R45 at this time and said R45 has a hip fracture due to fall. On 10/21/24 at 12 PM, R45's room was closed but can hear audible moaning. This surveyor entered R45's room. R45 was in the bathroom sitting in the toilet seat. V18 (Certified Nursing Assistant) was with R45. R45 was crying in pain. It's sore!, it is so painful! I can't take this please, I can't, please help me, it hurt's so bad. V18 asked this surveyor…

  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 before2024-02-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the safety of a resident while ambulating in the shower room. This applies to one of three residents (R1) in the sample of three reviewed for safety and supervision. This failure resulted in R1 falling and sustaining a fractured right humerus, a fractured nose and a right frontal lobe brain hemorrhage. The findings include: The facility face sheet for R1 shows she has diagnoses to include congestive heart failure, hypertension, chronic kidney disease and has a history of falls. The facility assessment dated [DATE] for R1 shows her to be cognitively intact and uses a walker for ambulation. The same assessment shows R1 requires moderate assistance with showering. The fall risk assessment dated [DATE] shows R1 to be at a high risk for falls. The facility state report dated 2/6/24 shows R1 was walking into the shower room for her shower when she fell and obtained fractures to her right arm, a laceration to her right side of her forehead…

  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 · D2024-11-06 · 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 ensure a resident (R1) was free from physical abuse of (R2) for two of three residents (R1, R2) reviewed for abuse in the sample of 7. The findings include: The State Report dated 10/27/24 for R1 showed, V1 (Administrator) was notified that R1 stated R2 smacked him. Investigation initiated. Staff attempting to assist in this situation and R2 kicked and struck the CNA (Certified Nursing Assistant). Residents separated from one another. R2 refused to let staff near him. R2 being sen out for further evaluation. Family of both residents notified. Provider notified. Police notified. Investigation completed. V9 (Laundry Aide) stated, when I was returning from break, R2 was at the door asking me for help to open the door so he can get out of his room, his roommate hit him. V5 stated that R2 has had a change in condition; the resident is currently experiencing altered mental status and aggressive behavior. He recently moved to the current room. This nurse 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 · F2024-10-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility to ensure dishes were handled in a sanitary manner to prevent cross contamination. This failure has the potential to affect all 89 residents in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 10/21/24 showed the facility's resident census as 89 residents. On 10/22/24 at 9:32 AM, R15 Dietary Aide placed dirty dishes and cups onto a dishwasher rack and pushed the rack into the dishwasher to be cleaned. Without washing her hands, R15 then walked over to a tray of dry, clean dishes and began placing those dishes onto a storage rack. R15 repeated the same process again, of loading dirty dishes into the dishwasher and immediately touching clean dishes without washing her hands. On 10/22/4 at 11:44 AM, V16 Dietary Manager stated, if one staff member is operating the facility's dishwasher, the staff member is to wash their hands after touching dirty dishes and before touching clean dishes. V16 stated, If they don't wash their hands in between, I would be…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-10-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide 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 ensure pressure ulcers were assessed, prescribed treatment orders were transcribed and provided, and treatment dressings were in place for residents with pressure ulcers. These failures apply to 4 of 5 (R179, R6, R66, R55) residents reviewed for pressure ulcers in the sample of 18. The findings include: 1. R179's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE], from another facility. Her diagnoses include COPD, unspecified dementia without behavioral disturbance, type 2 diabetes, multiple sclerosis, gastrostomy status, unspecified cerebral infarction. On 10/21/24 at 9:24 AM, V7 (Licensed Practical Nurse/LPN) provided wound care to R179. V7 removed the soiled dressing from her coccyx. A round open area to her coccyx was observed. V7 cleansed the wound, applied calcium alginate and foam dressing but did not apply the medicated cream to the wound bed. V7 said R179's treatment order was santyl and calcium…

  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 before2024-10-23 · 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

  Based on interview and record review that facility failed to ensure a resident with a diagnosis of congestive heart failure had daily weights performed as ordered for 1 of 18 residents (R15) reviewed for quality of care in the sample of 18. The findings include: R15's Face Sheet shows that she has diagnoses of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (CHF), myocardial infarction, atrial fibrillation, chronic kidney disease, shortness of breath, hypertension, chronic obstructive pulmonary disease and atherosclerotic heart disease. R15's Physician's Order Sheet shows an order dated 2/28/24 for daily weights for a diagnosis of CHF. R15's Weights and Vitals summary printed on 10/22/24 shows that between 7/13/24 and 10/22/24, R15 did not receive a weight on 7/13, 7/14, 7/15, 7/18, 8/7, 8/15, 8/16, 8/24, 8/29, 9/6, 9/14, 9/16, 9/26, 9/27, 9/28, 9/29, 10/2, 10/6, 10/8, 10/9, 10/13, 10/14, 10/16, 10/17, 10/19 and 10/21/24. On 10/22/24 at 12:58 PM, V2 (Director of Nursing) said that if weights are ordered daily for a resident, they should be…

  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 · D2024-10-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
  Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident received Passive Range of Motion (PROM) to her left upper and lower extremity and failed to ensure a splint was applied for 1 of 4 residents (R27) reviewed for range of motion in the sample of 18. The findings include: R27's Minimum Data Set assessment dated [DATE] shows that her cognition is intact, she has an impairment of one side of her upper and lower extremity and has no rejections of care. On 10/21/24 at 9:00 AM, R27 had a contracted left hand. There was no splint in place on R27's left hand. R27 said that she is unable to move her left arm or left leg due to a stroke. On 10/22/24 at 8:45 AM, R27 was laying in bed. R27 did not have a splint on her left hand. On 10/23/24 at 8:40 AM, R27 said that they do not do exercises (ROM) on her left arm or left leg. R27 said that she did have a brace for her left hand in the past but they have not put it on her recently. R27 said that she would love exercises done to her left…

  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 · D2024-10-23 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was experiencing increased depression received psychiatric services timely as prescribed. This applies to 1 of 18 residents (R29) reviewed for behavioral services in the sample of 18. The findings include: R29's face sheet shows he is a [AGE] year old male with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, restlessness and agitation, calculus of kidney, unspecified psychosis, insomnia, hypertension and anxiety. On 10/21/24 at 10:25 AM, R29 was observed sitting in his wheelchair outside of his room with his call light on. He said he needed to use the bathroom. V7 and V18 (Both Certified Nursing Assistant's) assisted R29 to the bathroom using the mechanical stand lift. R29 did not express any concerns or behaviors. On 10/22/24 at 3:00 PM, R29 was observed in his room lying in bed. He said has made self-harm threats in the past, but says…

  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 · D2024-10-23 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure a resident's medications were administered according to standards of practice for 1 of 18 residents (R15) reviewed for storage of medications in the sample of 18. The findings include: On 10/21/24 at 9:03 AM, R15 was sitting in a chair in her room eating breakfast. R15 had 8 pills in a medication cup on her bedside table. R15 stated, Those are my morning pills. There was no nurse present in the room. On 10/21/24 at 9:13 AM, V6 (Registered Nurse) said that she administered R15's morning medications already so she does not know what medications would have been on R15's bedside table. V6 said that medications should never be left in a resident's room and the nurse should always ensure that the resident takes the medications before leaving the resident. On 10/21/24 at 9:15 AM, V6 entered R15's room. The pills that were on R15's bedside table were gone. R15 stated, I just took my morning pills that you left, you know that I don't take them until after I am done with breakfast. On 10/22/24 at 12:58 PM, V2…

  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 · D2024-10-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement 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

  Based on interview and record review the facility failed to ensure an as needed antipsychotic was limited to 14 days and failed to ensure an as needed antianxiety medication had a stop date for 1 of 5 residents (R69) reviewed for psychotropic medications in the sample of 18. The findings include: R69's Physician's Order Sheet (POS) shows an order dated 8/30/24 for: Haloperidol Lactate (antipsychotic)-Give 0.25 ml (milliliters) by mouth every two hours as needed for agitation. There is no end date documented on the POS. R69's POS shows an order dated 8/30/24 for: Lorazepam (antianxiety) 0.5 mg (milligrams)-Give one tablet by mouth every two hours as needed for shortness of breath, air hunger or anxiety. There is no end date documented on the POS. R69's POS shows an order dated 10/8/24 for: Lorazepam 2 mg/ml-Give 0.5 mg by mouth every two hours as needed for restlessness or anxiety. There is no end date documented on the POS. On 10/22/24 at 1:35 PM, V2 (Director of Nursing) said that all psychotropic medications are ordered for only 14 days. V2 said that if after the 14 days, 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-12-21 · 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 observation, interview, and record review the facility failed to ensure a resident with dysphagia and nectar thickened liquids was provided supervision when drinking liquids in her room for 1 of 1 residents (R13) reviewed for safety and supervision in the sample of 19. The findings include: On 12/19/23 at 9:43 AM, R13 was sitting in a wheelchair in her room watching television. R13 had a pink liquid in a clear cup in her room sitting next to her on a stand. The pink liquid did not appear to be a nectar thick consistency. R13 was able to pick up the cup and bring it to her lips independently. R13 had a non productive cough present that sounded wet with rhonchi present and was audible without a stethoscope. On 12/19/23 at 12:21 PM, V3 CNA (Certified Nursing Assistant) stated R13 is her grandmother. V3 stated R13 is on a pureed diet and thickened liquids because she has swallowing problems. R13 failed her swallow evaluation recently; they said the swallow evaluation did not go to well and they are supposed to be having a meeting about it. V3 was feeding R13 and stated R13 is…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-12-21 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  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 an indwelling catheter bag and tubing were changed as ordered and failed to ensure a catheter drainage bag was kept below the level of the bladder for 2 of 2 residents (R280 & R62) reviewed for catheters in the sample of 19. The findings include: 1. R280's computerized face sheet printed 12/20/23 showed an admission date of 12/8/23 and diagnoses including but not limited to traumatic subarachnoid hemorrhage, aphasia (difficulty speaking), neurogenic bladder, and dysphagia (difficulty swallowing). R280's facility assessment dated [DATE] showed no severe cognitive impairment and staff assistance required for eating, hygiene, and dressing. R280's December 2023 physician order sheet showed an order to change the catheter drainage bag at the night shift every Sunday dated 12/8/23. On 12/19/23 at 9:43 AM, R280 was seated in a wheelchair in her room with a catheter drainage bag hooked underneath and inside a dignity bag. The catheter…

  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

“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

$34,753 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $14,505 — penalty dated 2025-01-15
• $20,248 — penalty dated 2024-10-23
• Medicare payment denial — starting 2024-11-15 for 11 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.

Part of a chain

This home belongs to TUTERA SENIOR LIVING & HEALTH CARE — 25 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 →

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

CMS files one row per role, so the 23 rows in the source record cover these 13 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.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in IL