Heritage Square
620 North Ottawa Avenue, Dixon, IL 61021 · Non profit - Other · 27 certified beds · (815) 288-2251 Medicaid only — no Medicare
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- its facility-reported quality-measure rating is low (1/5)
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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 held steady at 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 | 25.8% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 1.4% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 54.2% | 6.5% | check this* — see note marked star 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 | 4.8% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 23.7% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.1% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 33.7% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.7% | 21.7% | 17.1% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
Therapy staffing: this home’s payroll records show 2.39 therapist hours per resident per day in 2026Q1 — more than 100% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 84% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. 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 | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| 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 | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
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 27 beds and averages 23.1 residents a day — about 86% occupied, or roughly 4 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 6.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.53 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 5.89 hrs/resident/day on weekends vs 7.24 on weekdays — 19% thinner on weekends. RN hours go from 1.17 to 0.56 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%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
11 citations, most serious first — scroll within the box to see all.
- Potential for harm · Fcited before2025-09-24 · 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 ensure kitchen staff wore hair restraints and failed to ensure the freezer was in working order. This applies to all 24 residents residing in the facility. The findings include: The facility's Long-Term Facility Application for Medicare and Medicaid (CMS 671), dated 9/22/25, shows the facility census is 24. On 09/22/2025 at 9:30 AM, V3, Food Service Director, opened the freezer door. The ceiling contained ice drops. There were multiple boxes and containers of food items covered with ice and frost on the top shelves of the freezer. The freezer fan was running and making a very loud clanking noise. There was a food cart with loaves of bread and trays of foiled covered dishes, dated 8/16/25. The dishes were covered in ice, and some were attached to the shelf above them with ice. V3 said she was not sure what the dishes were, but they should be thrown out and said, the health department was here last week and told us the food items on the top shelf should be thrown out. The thermometer in the freezer showed 20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 handle mechanically altered food in a manner to prevent cross-contamination. This applies to 2 of 2 residents (R4 and R12) reviewed for dietary services in the sample of 11 and 4 residents (R7, R9, R11, and R16) outside the sample. The findings include: The plating of the 7/9/24 lunch service was observed from its initiation through its completion (11:17 AM until 11:30 AM) On 7/9/24 at 11:17 AM, V7 (Cook) was plating all meals including mechanical soft diets. During the plating, V7 touched numerous surfaces including oven handles, door handles, and the handle for the tray cart. V7 did not change her gloves when going from these high touch surfaces and then back to serving lunch. During the lunch service, V7 would use her gloved right hand, the same gloved hand that contacted door handles, to touch the residents' mechanical soft chicken tenders. V7 scooped the chicken with her gloved hand and placed it in the ladle. On 7/10/24 at 9:24 AM, V5 (Dietary Supervisor) stated, Staff should not be handling food after…
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 before2024-07-10 · 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 interview and record review, the facility failed to obtain orders and implement treatments for wounds to a residents feet upon admission to the facility for 1 of 1 residents (R13) reviewed for pressure ulcers in the sample of 11. The findings include: R13's Nurse's Notes, dated 6/17/24, showed, (R13) was admitted to the facility on [DATE]. A skin assessment was done and charted. Will continue to monitor. R13's Admit Shower Sheet, dated 6/17/24, showed the left foot had a 1 cm (centimeter) open area to the inner foot; a 1 cm area to the right inner foot that did not say it was open; and a 2 cm x 1 cm area to the right heel. The shower sheet was signed by the nurse. R13's admission Nursing Evaluation, dated 6/17/24, showed the following: 16) Left antecubital 3 cm x 3 cm bruise from IV (intravenous) site; 37) Right knee (front) 2 cm x 1 cm bruise; 38) Left knee (front) 24 cm long scar from knee surgery; 50) Left heel 2 cm x 1 cm necrotic area on heel; 51) Right toe(s) scab on outer area of big toe; and 52)…
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 · D2024-07-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 weight loss interventions for a resident with weight loss. This applies to 1 of 2 residents (R12) reviewed for weight loss in the sample of 11. The finding include: R12's admission Record (Face Sheet) showed diagnoses to include depression, anxiety, and dementia. R12 weight history documentation showed a weight of 127 pounds on 4/2/24 and 115.2 pounds on 5/4/24. (The electronic charting showed this was a weight loss of 9.4 percent.) R12's next documented weight was on 6/4/24 and was 123.7 pounds. R12's weight documentation did not show weekly weights were done from 4/2/24 to 5/4/24. On 7/10/24 at 11:04 AM, V5 (Dietary Manager) stated, I requested a re-weigh for her May to June weight loss but it fell through the crack. Her weight did go back up in June. I did talk to [V2, Direcor of Nursing] about that (the weight not being done), that it is an issue, that she was not re-weighed. V5 stated she spoke to the facility's Dietitian, and she agreed R12 needed to be re-weighed. V5 said, I requested the re-weigh because…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 was provided his prescribed mechanically altered diet and thickened liquids for 1 of 1 residents (R4) reviewed for mechanically altered diets in the sample of 11. The findings include: On 7/9/24 at 11:40 AM, R4 was sitting in his wheelchair at the dining room table for lunch. R4 had minced chicken strips with liquid in the bowl, thin sliced raw carrots with onions and a dressing in a small bowl, a whole brownie, soup in a cup, juice (in 12 ounce cup) and thickened water (in 12 ounce cup). At 11:47 AM, V9 (CNA/Certified Nursing Assistant) was at R4's table assisting him with his meal. V9 gave R4 a bite of chicken on a spoon and asked him if he swallowed it. R4 lifted the next bite of chicken from his bowl himself. V9 stated, (R4) is on a mechanical soft diet, but needs liquids mixed with his food. V9 stated R4 had chicken that is chopped and mixed with gravy, a brownie that is regular that she would put in a bowl with some milk. V9 stated the carrots in the small bowl were shredded and in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-10 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to doff (remove) personal protective equipment (PPE) for enhanced barrier precautions inside of the residents room for 1 of 2 residents (R4) reviewed for infection control in the sample of 11. The findings include: R4's Physician Orders showed orders, dated 6/18/24, for feeding tube care, flushes, and feedings. May use use enhanced barrier precautions per policy as needed for indwelling medical devices R4's Care Plan, dated 6/24/24, showed he is on EBP related to his feeding tube. R4 will have no negative effects from enhanced barrier precaution isolation protocol. R4's Face Sheet, dated 7/10/24, showed diagnoses including aphasia following cerebral infarction, dementia, type 2 diabetes mellitus, urinary tract infection, hypertension, hyperlipidemia, gastro-esophageal reflux disease, hypothyroidism, and other sequelae of cerebral infarction. On 7/9/24 at 9:19 AM, the sign on the door to R4's room showed he had EBP (enhanced barrier precautions) in place. The sign showed providers and staff must wear gloves and a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-14 · 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 ensure weekly measurements were completed for a resident with a pressure ulcer for 1 of 1 resident (R1) reviewed for pressure ulcers in the sample of 11. The findings include: R1's Care Profile, dated 9/14/23 showed medical diagnoses including type 2 diabetes mellitus, pneumonia, hyperlipidemia, dementia, constipation, disease of salivary glands, urinary tract infection, and hypertension. R1's Physician Orders, dated September 2023, showed, medihoney calcium alginate, apply to the coccyx topically every day and cover with a border dressing. R1's Care Plan, dated 8/23/23, showed, I am at risk for impaired skin integrity related to fragile skin and have actual impairment of skin integrity related to open area on coccyx and open area on great right toe. Follow facility protocols for treatment of injury. Monitor/document location, size and treatment of skin injury. Weekly treatment documentation to include measurement of each area of skin…
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 · D2023-09-14 · 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 implement fall interventions for residents at risk for falls, failed to review fall investigations, and failed to update resident care plans with new interventions after falls for 2 of 3 resident (R13, R15) reviewed for falls. The findings include: 1. R15's face sheet showed she was admitted to the facility on [DATE], with diagnoses to include cerebral arteriosclerosis, osteoarthritis, diabetes mellitus, hyperlipidemia, transient cerebral ischemic attack, and vascular dementia. R15's facility assessment, dated 6/21/23, showed she requires extensive assistance of staff for toileting and dressing and limited assistance of one staff for bed mobility and transfers. R15's facility incident reports, dated 7/18/23, 8/6/23, 8/14/23, 8/24/23, and 9/1/23, showed fall incidents occurring. R15's care plan initiated on 9/13/23 showed, I previously experienced a stroke and I am at risk for falls related to gait/balance problems and being unaware 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 · D2023-09-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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
Based on interview and record review, the facility failed to ensure intake and output monitoring was documented for a resident with an indwelling urinary catheter for 1 of 1 resident (R16) reviewed for intake and output and urinary catheters in the sample of 11. The findings include: R16's Face Sheet, dated 9/13/23, showed medical diagnoses including dementia, edema, vitamin B12 deficiency, atherosclerotic heart disease, hypertension, type 2 diabetes mellitus, depression, hyperlipidemia, chronic obstructive pulmonary disease, restless leg syndrome, insomnia, personal history of malignant neoplasm of the prostate, abdominal aortic aneurysm, cognitive communication deficit, low back pain, obstructive and reflux uropathy, dysphagia, tremor, muscle wasting and atrophy, and urinary tract infection. R16's Physician Orders, dated September 2023, showed, monitor intake and output every shift; change urinary catheter as needed if suspect infection, obstruction or compromised drainage; indwelling urinary catheter - diagnoses of urinary retention, neurogenic bladder status post TURP…
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 · D2023-09-14 · 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 ensure an air filter was on an oxygen concentrator and the the air filter holder on an oxygen concentrator was clean. The facility failed to ensure a nasal cannula and a humidification container on an oxygen concentrator was dated. This applies to 2 of 2 residents (R6 & R7) reviewed for oxygen therapy in the sample of 11. The findings include: 1. R6's Face Sheet, dated 9/13/23, showed medical diagnoses including angina, insomnia, cough, aortic valve disorder, nausea, atherosclerotic heart disease, hypertension, chronic obstructive pulmonary disease, and myocardial infarction. R6's Physician Orders, dated September 2023, showed, Administer oxygen per nasal cannula up to 6 liters per minute. Keep oxygen saturation at least 90 percent. R6's Care Plan, dated 6/8/23, showed, I have asthma and utilize supplemental oxygen. Advise resident to minimize contact with known offending allergens. Give nebulizer treatments and oxygen as ordered. The care plan did not have an intervention listed to keep the oxygen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-07-10 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
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 accurately submit payroll-based journal hours. This has the potential to affect all 16 residents. The findings include: The facility's 7/9/24 application for Medicare and Medicaid showed 16 residents in the health center. The Centers for Medicare and Medicaid Services (CMS) payroll-based journal (PBJ) report for January 1-March 31, 2024, showed the facility failed to have licensed nursing coverage 24 hours per day. This report specifically showed 1/13, 1/20, 1/28, 2/3, 2/11, 3/2, 3/7, 3/10, 3/17, and 3/24/24 as the dates not having coverage. The facility's first floor has sheltered care beds. The second floor has certified beds. The second-floor health center had a notice posted on the bulletin board dated 7/1/24, that showed this facility does not currently meet the minimum staffing ratios required by law. Posted at the direction of the Illinois Department of Public Health. On 07/09/24 at 10:24 AM, V2 (Director of Nursing/DON) said there is always a nurse on duty. On 7/9/24, V1 (Administrator) said there 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in IL
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 14A357. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-24, 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.