Lakeland Rehab & Healthcare Center

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.

49.1% 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 311 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 56.9% 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 137 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% 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 154 beds and averages 118.4 residents a day — about 77% occupied, or roughly 36 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 3.39 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.46 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 2.99 hrs/resident/day on weekends vs 3.56 on weekdays — 16% thinner on weekends. RN hours go from 0.50 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 39% 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.

28 citations, most serious first. The 15 most serious are shown; the remaining 13 are one tap away and print in full.

• Actual harm · G2026-06-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to safely transport 1 of 3 (R1) residents reviewed for accidents in a sample of 4. This failure resulted in R1's left foot getting caught in her wheelchair wheel during transport and resulted in R1 sustaining an acute mildly displaced fracture of the distal fibula and medial malleolus of the left leg.This past non-compliance occurred from 5/16/2026 to 5/18/2026.R1's admission Record documented an admission date of 4/4/2025 with diagnoses of type two diabetes mellitus, complete atrioventricular block, chronic kidney disease, non-st elevation myocardial infarction and weakness among others. R1's MDS (minimum data set) dated 3/23/26, documents R1 with a BIMS (brief interview for mental status) score of 10 out of 15 total which indicates R1 has moderate cognitive impairment. This same MDS documents R1 has impairment to both upper and low extremities, uses a wheelchair for locomotion and is dependent on staff for most activities of daily living, including…

  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 · Past Non-Compliance
• Actual harm · Gcited before2025-02-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent peer to peer sexual abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. This failure resulted in R1, who is cognitively impaired and incapable of giving informed consent to inappropriate sexual touching and having unsolicited sexual comments directed toward her. These actions would cause a reasonable person to experience feelings of guilt, embarrassment, anger, and shame. Findings include: R1's Face Sheet documented an admission Date of 6/29/23 and listed diagnoses including Osteoarthritis and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe impaired cognition. R2's Face Sheet documented an admission Date of 9/17/24 and listed diagnoses including Diabetes Type 2 and End Stage Renal Disease Dependent on Dialysis. R2's MDS dated [DATE] documented a BIMS score of 14, indicating R2 is cognitively intact. R2's Nursing Progress…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-11 · 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, the facility failed to remove surgical staples and to obtain an x-ray as ordered for 1 of 11 residents (R1) reviewed for quality of care in the sample of eleven. This failure resulted in R1's surgical hip incision becoming infected and requiring antibiotic therapy. Findings include: R1's Face Sheet documented an admission Date of 12/27/23 and listed diagnoses including Congestive Heart Failure, Anxiety Disorder, and Chronic Kidney Disease. R1's 1/5/24 Minimum Data Set (MDS) documented that R1 had severe deficits in cognitive function. R1's Nursing Progress Notes documented the following: On 1/29/24 at 8:10am: Continues to complain of severe pain right hip/right leg. Had hydrocodone and ativan around 3:20am, then Tylenol at 7:12am. No relief. Moaning. Will not sit up in wheelchair straight. Total assist with toileting and transfer this morning, unable to stand on right leg. No internal/external rotation of extremities noted. Complains of pain when right leg or hip touched or when right leg is moved. Called (V14, Physician) office and notified 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure timely assistance was provided for toileting needs for 1 (R56) of 6 reviewed for Activities of Daily Living in the sample of 51. This failure resulted in R56 expressing undue feelings of frustration, embarrassment, and neck pain. Findings Include: R56's admission Record documented an original admission date to the facility as 7/1/22. R56 is documented as being a [AGE] year old female with diagnoses including but not limited to: Secondary Parkinsonism, Unspecified; End Stage Renal Disease; Nontraumatic Subarachnoid Hemorrhage, Unspecified, etc. R56's Minimum Data Set (MDS) with an Assessment Reference Date of 2/27/24 documented a Brief Interview for Mental Status Score of 13, indicating she's cognitively intact. The same MDS documented in Section GG0130, Dependent care for toileting hygiene. Section GG0170 also documented a dependent status for toileting transfer. Section H0300 documented R56 as being frequently incontinent. R56's Plan of Care…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-14 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure residents are free from abuse for two of three residents (R2 and R6) reviewed for abuse in the sample of 3. This failure resulted in R6 experiencing having clothing placed over his mouth twice in an attempt to quiet him. A reasonable person would also experience feelings of humiliation, intimidation, fear, emotional distress, and helplessness as a result. This past non-compliance occurred between 4/13/24 and 4/16/24. Findings include: 1.R6's face Sheet documented an admission date of 2/24/22, and diagnoses including Autistic Disorder, Dysphagia, Repeated Falls, and Unspecified Intellectual Disabilities. R6's Minimum Data Set (MDS) dated for 3/12/2024, documents that R6 has a Brief Interview for Mental Status (BIMS) score of 3, indicating that R6 has severe cognitive impairment. The same MDS documents that R6 is totally dependent on at least two persons assist for upper and lower body dressing. On 5/10/2024 at 1:40pm, attempted interview with R6 but due to severe cognitive impairment, R6 was unable to answer…

  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 · Past Non-Compliance
• Potential for harm · D2026-04-13 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to notify the family of a change in condition for 1 (R1) of 3 residents reviewed for notification of changes in the sample of 4. The Findings Include:R1's admission Record documented an admission date of 09/17/2024 and included diagnoses of acute osteomyelitis of right ankle and foot, chronic obstructive pulmonary disease, type 2 diabetes mellitus, generalized anxiety, end stage renal disease, chronic diastolic heart failure, anemia in chronic kidney disease, and dependance on renal dialysis.R1's Care Plan documented a focus area of R1 needs dialysis related to renal failure. Corresponding intervention included, do not draw blood or take blood pressure in the right arm with graft, encourage resident to go for the scheduled dialysis appointments on Monday, Wednesday, and Friday, and monitor labs and report to the doctor as needed.R1's Progress Note dated 03/27/2026 with a time of 4:58 A.M. authored by V8 (Licensed Practical Nurse/LPN) documented R1 refused to get up for dialysis treatment this morning. R1's Progress Note 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-02 · 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 ensure residents were turned and repositioned to prevent skin breakdown for 1 of 3 (R4) residents reviewed for quality of care in the sample of 14. Findings Include: R4's admission Record with a print date of 04/02/26 documents R4 was admitted to the facility on [DATE] with diagnoses that include heart disease, diabetes, kidney disease, hypertension, osteoarthritis, and dementia. R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 10, indicating a moderate cognitive deficit. Section H, Bladder and Bowel, documents that R4 is always incontinent of urine and bowel. Section M, Skin Conditions, documents that R4 has Moisture Associated Skin Damage (MASD) with skin and ulcer/injury treatments of a pressure reducing device for chair and bed, applications of nonsurgical dressings, and application of ointments/medications.R4's current Care Plan documents a Focus area of, (R4) has an ADL (activities of daily…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-04-02 · 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 interview and record review the facility failed to ensure physician orders were followed and referrals to specialist were obtained for treatment of a Urinary Tract Infection (UTI) for 1 of 3 (R1) residents reviewed for urinary infections in the sample of 14.Findings Include:R1's admission Record with a print date of 4/2/26 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, Chronic Kidney Disease (Stage 5), hypertension, morbid obesity, muscle weakness, hydrocele, and compression fracture of vertebrae. R1's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 01, indicating a severe cognitive deficit. Section H, Bladder and Bowel, documents that R1 has occasional urinary incontinence. R1's Care Plan documents a Focus area of, The resident has bladder incontinence R/T (related to) confusion. Date Initiated: 09/27/2024. This Focus area includes the intervention of, Monitor/document for s/sx (signs/symptoms) UTI (urinary tract…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-05 · tag F0803 — failed to meet residents' dietary needs — isolated
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to prepare potatoes according to the recipe for 3 of 4 (R2, R15, R24) residents reviewed for meal service in the sample of 26.Findings include: 1.R2's admission Record with a print date of 3/5/2026 documents R2 was admitted to the facility on [DATE] and included diagnoses of cerebrovascular disease, aphasia, cerebral infarction, dysphagia, and hemiplegia and hemiparesis following cerebra infarction affecting right dominant side.R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, which indicates R2 has a moderate cognitive deficit.R2's current Care plan documents a Focus area of (R2) has a swallowing problem Coughing or choking during meals or swallowing med (medications). Dated 03/06/2025. This Focus area includes the interventions of, All staff to be informed of resident's special dietary and safety needs. Date Initiated: 03/06/2025. Instruct the resident to eat in an upright position, to eat…

  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 before2025-07-28 · tag F0803 — failed to meet residents' dietary needs — pattern
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  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 menus were followed for 4 of 6 (R57, R24, R13, and R119) residents reviewed for nutrition in the sample of 56. Findings include:1. R57's admission Record with a print date of 7/24/25 documents R57 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, morbid obesity, dementia, and gastroesophageal reflux disease.R57's MDS (Minimum Data Set) dated 5/31/25 documents a BIMS (Brief Interview for Mental Status) score of 03, indicating a severe cognitive deficit.R57's current undated Care Plan documents a Focus area of (R57) has nutritional problem or potential nutritional problem, altered diet. Regular diet, pureed texture, nectar thick liquids. This same Focus area includes an intervention to Provide, serve diet as ordered. Monitor intake and record q (every) meal.R57's Medication Review Report dated 7/24/25 documents a physician order for regular diet, pureed texture, nectar thick liquids with a start…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-07-28 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to administer intravenous medications according to professional standards of practice to 2 of 2 residents (R117 and R118) reviewed for intravenous medications in the sample of 56. Findings include:1. R117's admission Record documents an initial admission date of 10/23/2023 and diagnoses including in part sepsis, infection, and inflammatory reaction due to indwelling urethral catheter, stage 3 pressure ulcer of right heel and left heel, and osteomyelitis of ankle and foot.R117's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 13 indicating R117 has intact cognition.R117's Order Summary Report dated 7/24/2025 documents and order to flush Peripherally Inserted Central Catheter (PICC) with 10 milliliters (ml) of normal saline followed by 5 ml Heparin post medication administration every day shift with a start date of 7/21/25, R117 required enhanced barrier precautions related to wounds, urinary…

  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 · D2025-07-28 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  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 proper infection prevention and control practices were used during resident care for 2 of 5 residents (R117 and R118) observed for infection prevention and control in the sample of 56.Findings include:1. R117's admission Record documents an initial admission date of 10/23/2023 and diagnoses including in part sepsis, infection, and inflammatory reaction due to indwelling urethral catheter, stage 3 pressure ulcer of right heel and left heel, and osteomyelitis of ankle and foot.R117's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 13 indicating R117 has intact cognition.R117's Order Summary Report dated 7/24/2025 documents and order to flush Peripherally Inserted Central Catheter (PICC) with 10 milliliters (ml) of normal saline followed by 5 ml Heparin post medication administration every day shift with a start date of 7/21/25, R117 required enhanced barrier precautions related 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-18 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to report to the facility Administrator or his/her designated representative an incident of peer to peer sexual abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings include: R1's Face Sheet documented an admission Date of 6/29/23 and listed diagnoses including Osteoarthritis and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe impaired cognition. The same MDS documented that R1 is dependent on staff for transfers and wheelchair mobility. R1's Care Plan dated 1/31/25 documented a problem area, The resident has a behavior problem 1/28/25, (R1) involved in a resident to resident touching incident with corresponding interventions, Changed (R1's) room, added 1/28/25, and Every 15 minute checks for 24 hours, added 1/28/25. R2's Face Sheet documented an admission Date of 9/17/24 and listed diagnoses including Diabetes…

  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 · D2025-02-18 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report, investigate, and further prevent peer to peer sexual abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings include: R1's Face Sheet documented an admission Date of 6/29/23 and listed diagnoses including Osteoarthritis and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe impaired cognition. The same MDS documented that R1 is dependent on staff for transfers and wheelchair mobility. R1's Care Plan dated 1/31/25 documented a problem area, The resident has a behavior problem 1/28/25, (R1) involved in a resident to resident touching incident with corresponding interventions, Changed (R1's) room, added 1/28/25, and Every 15 minute checks for 24 hours, added 1/28/25. R2's Face Sheet documented an admission Date of 9/17/24 and listed diagnoses including Diabetes Type 2 and End Stage Renal Disease Dependent on Dialysis. R2's…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-10 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 residents were safe from misappropriation of a controlled substance medication for 1 of 3 residents (R2) reviewed for misappropriation in a sample of 8. The findings include: R2's facility Initial Report dated 8/20/24 documents in part: The purpose of this letter is to notify The Department of a possible drug diversion. It was noted that resident Received his 8am dose of morphine but when the nurse went to give the 10 am dose the morphine could not be located. All notifications have been made. The facility has initiated an investigation into the matter. A final report will follow. R2's facility Final Report dated 8/26/24 documents in part: The purpose of this letter is to notify The Department of our conclusion of the investigation into a possible drug diversion. Licensed staff had administered the resident's 8 am dose. At 10 am when the Licensed Nurse went to administer the morphine, the bottle of morphine could not be located. The physician, POA (Power of Attorney), (City) Police and the Ombudsman were notified.…

  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

“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

$86,553 in federal fines across 3 penalties.

• $16,350 — penalty dated 2026-06-03
• $58,737 — penalty dated 2025-02-18
• $11,466 — penalty dated 2024-05-14

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 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

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 $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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.

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