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Eldorado Rehab & Healthcare

1001 A Jefferson Street, Eldorado, IL 62930 · For profit - Limited Liability company · 99 certified beds · (618) 273-3353 Medicare & Medicaid certified

Call the home — (618) 273-3353 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 2023Behavioral-health or dementia-care citations — no harm found (F0744, F0758)
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1405 Locust St · (618) 273-3321 · Call to confirm hours
Pharmacy
1409 Locust St · (618) 273-8111 · Call to confirm hours
Grocery
U.s. Hwy. 45 N. · (800) 576-4377 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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
Short-stay residentsrehab / post-hospital 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 improved from 1 to 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.0%13.4%15.4%worse
Long-stay residents who lose too much weight1.9%6.3%5.4%better
Long-stay residents with a catheter left in their bladder3.4%0.9%0.9%worse
Long-stay residents with a urinary tract infection3.8%1.5%2.0%worse
Long-stay residents with depressive symptoms12.9%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.0%3.1%3.3%worse
Long-stay residents whose ability to walk worsened29.7%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication31.5%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers8.6%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control28.2%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table30.1%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.4%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine59.0%63.1%79.4%worse
Short-stay residents rehospitalized after admission34.7%26.1%22.6%worse
Short-stay residents with an outpatient ER visit14.0%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.352.021.67worse
Long-stay outpatient ER visits per 1,000 resident days7.602.221.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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

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

42.3% 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 60 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.3%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
60.9%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 60.9% 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 23 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.3%CMS range 33.3–54.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.0–16.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge60.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge52.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened10.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.0%CMS range 4.8–15.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.48
RN hours/ resident / day
0.47
LPN hours/ resident / day
2.12
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.56
RN hoursweekends
36.2%
Total nursing turnover
16.7%
RN turnover

How full it usually is: this home is certified for 99 beds and averages 67.4 residents a day — about 68% occupied, or roughly 32 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 2.84 hrs/resident/day on weekends vs 3.16 on weekdays — 10% thinner on weekends. RN hours go from 0.44 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 36% 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

4
deficiencies at the latest standard inspection (2025-04-17)
19
at the previous standard inspection (2024-02-16)

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.

ABCDEFGHIJKL

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 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · Dcited before2025-11-26 · 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 interview, observation and record review, the facility failed to provide nutritional supplements as ordered for 2 of 3 residents (R1 and R13) reviewed for nutrition in the sample of 17.Findings include:1. R1's admission record dated 11/25/25 documents an admission date of 10/18/21. The same admission record documents diagnosis including but not limited to muscle weakness, vitamin deficiency, vitamin D deficiency, constipation, thrombocytosis, hyperlipidemia, osteoporosis, reduced mobility, and unsteadiness on feet.R1's physician order sheet dated 11/25/25 documents the following current orders including but not limited to health shake to be administered one time per day at lunch with a start date of 12/11/24, power pudding at lunch and supper, and ice cream at lunch both with a start date of 7/31/25.R1's current care plan documents a focus area indicating R1 is at risk for weight loss dated 10/18/21. Interventions for that focus area include but are not limited to antidepression medication as ordered…

    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 · D2025-04-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to develop a comprehensive person centered Care Plan for 1 (R43) of 19 residents reviewed for comprehensive care plans in a sample of 33. Findings include: R43's admission Record documents an admission date to the facility on 1/18/2025 with diagnoses including dementia, Alzheimer's dementia, acute kidney failure, urinary tract infection, atrial flutter, diverticulosis, diabetes mellitus type 2 and general anxiety disorder. R43's Care Plan in the Electronic Health Record (EHR) documented only two focus areas that included: Advanced directives and long term residency. The Care Plan is undated but lists an admission date of 1/18/2025. On 4/16/2025 at 9:15AM, V31 (Care Plan Coordinator) reviewed R43's EHR and said R43's Care Plan was never developed as far as she could tell. V31 said it only has two focus areas, advance directives and long term residency. V43 said it looks like R43's Care Plan was started but not finished. V43 said she was not the Care Plan Coordinator at the time R43's Care Plan was supposed to be developed. V31…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · 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 3. R7's admission Record documented R7 was admitted to the facility on [DATE] and include diagnoses of muscle weakness (generalized), unsteadiness on feet, and other reduced mobility. R7's MDS dated [DATE] documented a BIMS score of 14, indicating R7 was cognitively intact. In the section titled Functional Abilities under Self-Care, the MDS documented R7 requires substantial/maximal assist for showering/bathing, meaning the helper does more than half the effort . On 04/14/25 02:25PM, R7's hair appeared greasy and unkempt/uncombed. R7 stated We don't get our showers on time. We often only get a shower once a week. On 04/16/25 at 10:05 AM, R7 stated that her shower days are scheduled for Mondays and Thursdays. On 04/16/25 09:07AM, R7's Skin Monitoring Comprehensive CNA Shower Review documentation received from V1 from February 1, 2025 through April 12, 2025 documented that R7 received showers on printed shower sheets obtained from V1 documented R7 had showers on the following days: 2/2/25, 2/9/25, 2/14/25,…

    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 · D2025-04-17 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure bed rails/enablers were installed in accordance with manufacturer's recommendations and specifications for 1 (R7) of 1 resident reviewed for bed rails in the sample of 33. Findings include: R7's admission Record documented R7 was admitted to the facility on [DATE] and included diagnoses of muscle weakness (generalized), unsteadiness on feet, other reduced mobility, cerebral infarction, unspecified, and hemiplegia, unspecified affecting left nondominant side. R7's Minimum Data Set (MDS) dated [DATE] lists her functional limitation in range of motion impairment as on one side for upper extremity and lower extremity. R7 MDS documented she uses a wheelchair as a mobility device, and requires substantial/maximal assistance in the following areas: upper and lower body dressing, roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed, and for lying to sitting on side 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
  • Potential for harm · D2025-04-17 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 develop a plan for appropriate treatment and services for a resident with dementia for 1 (R43) of 19 residents reviewed for dementia care in a sample of 33. Findings include: R43's admission Record document she was admitted to this facility on 1/18/2025 and include a diagnosis of Alzheimer's dementia. R43's Minimum Data Set (MDS) dated [DATE], documented R43 has severe cognitive impairment and could not participate in cognitive testing. This same MDS documented R43 needs maximum to total assistance for all activities of daily living. R43's Care Plan documented two focus areas that included: Advanced directives and long term residency. The Care Plan is undated but lists an admission date of 1/18/2025. R43's Care Plan did not include a plan for R43's Alzheimer's dementia or cognitive decline. On 4/16/2025 at 9:15 AM, V31 (Care Plan Coordinator) reviewed R43's Care Plan in the EHR and said R43's Care Plan was never developed. V43 said it looks like R43'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were administered safely for 2 of 5 residents (R2 and R3) reviewed for medication administration in sample of 7. The findings include: R2's admission Record documents an admission date of 7/27/2017 and includes diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Reduced Mobility, Anxiety, and Major Depressive Disorder. R2's Minimum Data Set (MDS) dated [DATE] documents in Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 is cognitively intact. The same MDS documents in section E, Behaviors, is coded 0 for behaviors. R2's Order Summary Report dated 8/28/2024 does not include orders for Nystatin Powder. R2's Care Plan with a revision date of 7/27/24 does not include focus area or interventions addressing behaviors or R2's ability for self-administration of medications. On 8/28/2024 at 11:10 AM, R2 was observed sitting in her room. A bottle…

    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 · F2024-02-16 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 keep resident care areas and equipment clean and in a good state of repair. This has the potential to affect all 60 residents living in the facility. Findings include: On 02/06/24 at 12:14 PM, Dining room observed having brown ceiling tiles around ceiling vent area. On 02/08/24 at approximately 9:59 A.M., V4 (Maintenance Supervisor) and V11 (Regional Maintenance) were asked about the vent in the dining room with discolored tiles around it. V4 stated that he was aware of the discoloration of the ceiling tiles around the vent. V4 stated that it was on his list to do he has just been busy and it hasn't been that way long. V11 asked V4 if he had tiles available and V4 replied yes. On 02/06/2024 at 09:00 AM, observation in R10's room revealed the following: cove base in the bathroom ripped, dry wall exposed and ripped, dust and debris noted where the cove based stopped. On 02/06/2024 at 09:04 AM, observation in R24 and R212's room revealed the following: bathroom sink dripping, mildew build up around faucet and…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-02-16 · 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 failed to ensure that food items in the kitchen were properly stored/labeled and equipment was properly cleaned and maintained. This failure has the potential to affect all 60 residents residing in the facility. The Finings Include: During the initial tour of the facility on 2/6/24 at 8:40 AM the following concerns were noted: 1. A one gallon container of milk was in the refrigerator without a lid and not dated/labeled. 2. An open bag of shredded white and yellow cheese was found in the reach in refrigerator opened and not dated. The white shredded cheese was not sealed open to air in original bag. 3. A tray of drinks not labeled, not dated and uncovered were found in the reach in refrigerator. V40 (Corporate Director of Culinary Services) stated that they are drinks for the day for the residents. 4. The deep fryer located next to the oven was found to have food crumbs on the edges of it and floating in oil. 5. The walk-in freezer was found with the door not latched and ice accumulation on the floor under the bottom rack…

    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 · F2024-02-16 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
    Have a plan that describes the process for conducting QAPI and QAA activities.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview the facility failed to maintain documentation of holding quarterly Quality Assurance and Performance Improvement meetings (QAPI). This has the potential to affect all 60 residents residing in the facility. The Findings Include: During the investigation and review of facility records no evidence of quarterly QAPI meeting attendance or meeting information was found or produced by the facility. On 2/9/24 at 2:30 PM, V1 (Administrator) stated that he is not able to find any documentation of minutes or attendance sheets prior to January 2024 for the facility's quarterly QAPI meeting. V1 went on to state that he started his employment at this facility in January 2024 and no QA information is able to be accessed prior to that. The Long Term Care Facility application for Medicare and Medicaid dated 2/6/24, documents 60 residents reside in the facility.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-02-16 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's 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 provide activities that met resident goals and preferences for five (R7, R13, R14, R26, and R27) of five residents reviewed for activities out of a sample of 40. Findings include: 1. The facility's February 2024 activities calendar documented 2/8/24 10:00 AM sensory, 10:30 AM Valentine's Day crafting, and 11:00 AM social gathering. On 2/8/24 at 10:16 AM, V5 (Activities Director) was in the main dining room directing the sensory activity. 3 residents were in their wheelchairs around the table. 1 of the residents was asleep, 1 of the residents did not have an activity device but was scrolling on her phone, and 1 was using a fidget board. On 2/8/24 at 10:19 AM, another resident was wheeled into the dining room to participate in the activity and fell asleep in her wheelchair. On 2/8/24 at 10:22 AM, 5 residents were sitting around the table in the dining room with 3 of them asleep in their wheelchairs, 1 blankly staring at nothing, and 1 was with a fidget board in front of her. On 2/8/24 at 10:30 AM, V5 placed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · D2024-02-16 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide person-centered care plan meetings for 1 (R11) of 17 residents reviewed for care planning in a sample of 40. Findings Include: On 2/8/2024 at 9:15 AM, R11 was alert and oriented and stated she has never been invited to a care plan meeting, verbally or in writing. R11 stated, being here almost 3 years and have not been to a meeting, and I do not have a primary medical representative. R11's electronic medical record care plan meeting for quarterly and annual conferences documents that care plan letters were mailed to the patient medical representative with no response. On 02/08/24 at 08:49 AM, V7 (Care Plan/ Minimum Data Set Coordinator) stated, R11 was verbally notified of care plan meetings but nothing was given to R11 on paper, but R11 was reminded of the date and time of meetings. V7 states, the care plan letters were mailed to family, but family never responded. R11's MDS (Minimum Data Set) with Assessment Reference Date of 11/3/2023 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R11…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    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 provide unconflicted lunch meal and smoking schedules for one resident (R21) of 17 residents reviewed for accommodation of need in the sample of 40. Findings include: R21's Face Sheet documented an admission date of 7/27/17, and listed diagnoses including History of Cerebral Infarction, Hypertension, and Nicotine Dependence. The facility's Meal Schedule documented the lunch meal service begins at 12:00pm. On 02/06/24 at 11:15am, R21 was alert and oriented to person, place, and time. R21 stated she always eats in her room, and her lunch meal is frequently cold by the time she eats it. R21 stated she gets her tray as late as 1:00pm, which interferes with the 1:00pm scheduled smoking time. On 02/06/24 at 12:52pm, R21 was observed waiting by the exit to go outside to smoke. R21 stated staff had just informed her they probably won't go out until about 1:30pm. On 02/06/24 at 1:03pm, R21's lunch tray was observed sitting on her overbed table. The plate was covered with a metal plate cover. On 02/06/24 at 01:28pm,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-16 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 Practitioner Orders for Life-Sustaining Treatment (POLST) status reflected resident wishes as desired throughout the Electronic Health Record for one (R58) of one residents reviewed for advanced directives in the sample of 40. Findings Include: R58's Face Sheet documented an admission date to the facility as [DATE]. This document also listed R58's diagnoses including, but not limited to: Acute kidney failure, Dysphagia, Parkinson's disorder without dyskinesia. R58's POLST form, scanned into R58's Electronic Health Record, with a [DATE] signature date by R58, documented a Do Not Resuscitate status. Review of the Advanced Directive tab, as well as the informational screen heading listed in R58's Electronic Record documented R58's status as being attempt CPR (Cardiopulmonary Resuscitation). On [DATE] at 2:59 PM, V1 (Administrator) verified that the Advanced Directive status listed for R58 do not correlate. V1 confirmed that the code status should…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-16 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 identify and assess adaptive equipment in order to ensure safety and freedom for normal movement for one (R24) of one residents reviewed for physical restraints in the sample of 40. The Findings Include: Review of R24's Face Sheet documents an admission date to the facility as 6/1/22 and includes the diagnosis other reduced mobility, major depressive disorder, spinal stenosis, sciatica, and anxiety disorder. R24's current month of February 2024 Physician Orders does not have an order for the use of a self-releasing seatbelt. R24's Annual Minimum Data Set (MDS) with assessment reference date as 1/12/2024 documents a Brief Interview for Mental Status score of 3, indicating significant cognitive impairment. This same assessment documents R24 is dependent on staff for chair/bed transfer, sit to stand, and sit to lying position. Review of section GG0115 documents no range of motion impairment in her upper or lower extremities. R24's current care plan has a category for fall with the interventions as follows all…

    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 · D2024-02-16 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) coding for one (R59) of 17 reviewed for Minimum Data Sets in the sample of 40. Findings Include: R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family member/Power of Attorney/POA) and V22 (Family member). R59's (Name of town) Primary Care record found in R59's Electronic Health Record, documented a visit on 12/7/23 with a chief complaint being to establish care. This document stated, Patient has been here in the past. It has been over 4 years since he was last seen in this clinic. He is here…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-16 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide individualized plan of care revisions to meet the needs for one (R59) of 17 residents reviewed for care plans in the sample of 40. Findings Include: R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family Member/Power of Attorney/POA) and V22 (Family Member). R59's Minimum Data Set with an assessment reference date of 1/4/24 documented a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. R59's (Name of town) Primary Care record found in R59's Electronic Health Record, documented 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-16 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 provide services to improve or maintain Range of Motion status and functioning for one (R11) of 17 residents reviewed for Range of Motion in the sample of 40. Findings Include: The Resident Profile section of R11's Electronic Record documents an admission date to the facility of 8/20/21 with diagnoses listed but not limited to type 2 diabetes mellitus, cerebral infraction, unspecified, Hemiplegia, unspecified affecting left nondominant side, hyperkalemia, history of falls, weakness. On 2/06/24 09:26, R11 was observed with a brace to the left lower extremity. R11 stated she had a stroke in 2011. R11 stated, aides do not do any range of motion program, other than 2 times a week when in the shower. The certified nursing assistants will move left hand fingers to clean hand. R11 stated after being discharged from therapy she was told she would be put in a restorative program, but never was and she would like to be. R11's Physical Therapy Plan of Care dated 2/13/2023 documents a referral for skilled physical therapy…

    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 · D2024-02-16 · 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 Based on observation, interview, and record review, the facility failed to ensure residents at risk for elopement were accurately assessed and incidents of elopement were appropriately identified and thoroughly investigated for 2 (R59 and R24) of 6 reviewed for accidents and supervision in the sample of 40. This failure resulted in R59, who has a diagnosis of dementia with severe cognitive impairment, eloping from the facility on 12/29/23. Findings Include: 1. R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family Member & Power of Attorney/POA) and V22 (Family Member). R59's Minimum…

    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 · D2024-02-16 · 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

    Based on interview, observation, and record review, the facility failed to provide aseptic catheter care for one resident with a history of Urinary Tract Infections (R9) of three residents reviewed for catheters in the sample of 40. The findings include: R9's Face Sheet documented an admission date of 11/23/22 and listed diagnoses including Benign Prostatic Hypertrophy (BPH) with Lower Urinary Tract Symptoms and History of Urinary Tract Infection. R9's Care Plan dated 12/22/23 documented a problem area, readmission to the facility following hospitalization following diagnoses of Sepsis, Pneumonia, (and) UTI (Urinary Tract Infection). An 8/31/23 Urinalysis with Reflex Culture documented, Culture result: Organism identification: Enterococcus Faecium. On 02/08/24 at 09:25am, V2 (Director of Nurses) stated R9 has an indwelling catheter due to BPH with urinary retention. V2 stated R9 has a history of UTIs. On 02/08/24 at 11:41am, staff were observed providing catheter care for R9. R9 was alert to himself only. A clean field with clean linens and clean trash bags had been set up on 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
  • Potential for harm · Dcited before2024-02-16 · 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 provide a residents protein of choice for one resident with weight loss (R7) of four residents reviewed for weight loss in the sample of 40. Findings include: R7's Face Sheet documented an admission date of 12/3/16 and listed diagnoses including Parkinson's Disease, Gastro-Esophageal Reflux Disease, and Diabetes Type 2. R7's Physicians Orders documented an order for a carbohydrate controlled diet of regular consistency and thin liquids, fortified milk at breakfast, butter to hot vegetables at lunch and supper, fortified juice at lunch, and double protein at breakfast. R7's Weight Record documented the following weights: 02/04/2024 153 lbs(pounds) 01/14/2024 153 lbs 01/03/2024 156 lbs 12/03/2023 154.7 lbs 11/12/2023 153 lbs 11/07/2023 149.2 lbs 10/29/2023 149 lbs 10/22/2023 142.2 lbs 10/01/2023 149 lbs 09/22/2023 157.2 lbs 09/03/2023 159.4 lbs A Registered Dietician Note for Annual (Assessment) dated 1/22/24 stated,Resident is a [AGE] year…

    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 · D2024-02-16 · 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, observation, and record review, the facility failed to ensure residents medication regimens were free from unnecessary medication for three (R18, R50 R24) of five residents reviewed for unnecessary medications in the sample of 40. Findings include: 1. R50's Face Sheet documented an admission date of 10/27/22 and listed diagnoses including Unspecified Dementia without Behavior Disturbance, and Bipolar Disorder. R50's Physicians Orders documented orders for Citalopram 20 mg (milligrams) one tablet daily with a start date of 10/28/22, Risperdal 0.5mg one tablet twice daily with a start date of 11/15/22, Benztropine 0.5mg one tablet twice daily with a start date of 7/25/23,and Lorazepam 1mg one tablet three times daily with a start date of 11/15/22. R50's Behavior Tracking for February 2024 documented that R50 is being monitored for the behaviors of daily exit seeking and wandering, being sad about her family not visiting, and being resistive to personal care. A Consultant Pharmacists Medication Regimen Review Communication dated 6/23/23 documented Route 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-16 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide therapeutic diets per physician's orders for two (R18, R48) residents of four residents reviewed for therapeutic diets in the sample of 40. Findings include: R18's Face Sheet documented an admission date of 3/10/22 and listed diagnoses including Dementia, Hypertension, and Type 2 Diabetes. R18's Physicians Orders documented a diet order for a regular diet with regular consistency and thin liquids. R48's Face Sheet documented an admission date of 10/27/23 and listed diagnoses including Dementia, Hypertension, and Multiple Sclerosis. R48's Physicians Orders documented a diet order for regular diet with mechanical soft texture with extra gravy/sauce and thin liquids. R48's Speech Therapy Plan of Care dated 10/30/23 documented, Reason for referral: Patient is a [AGE] year old female admitted to this facility post hospitalization for Covid-19, Pneumonia, and Acute on Chronic Respiratory Failure. Patient has a history of Dementia and 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-16 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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, record review and interview the facility failed to ensure that residents had alternative meal options similar or equivalent nutritive value of the main meal selection for three of three residents (R10, R11 and R46) reviewed for meal alternatives in a sample of 40. The Findings Include: On 2/6/24 at 11:00 AM, V3 (Cook/Dietary Manger) stated that he did not have an alternate made today, but that he usually just makes a grilled cheese, peanut butter sandwich or turkey sandwich if the residents do not like what they have on the menu. V3 stated there is not a planned alternate meal option and he just uses what is quick and available. V3 stated that the steam table today for lunch would have the following: Fiesta chicken (regular, mechanical soft, and pureed), Mexican rice (regular and pureed), elote corn and creamed corn, breadstick/bread, and snickerdoodle cookie. The only items observed on 2/6/24 at 12:00 PM during [NAME] meal observation were of the main meal selection while lunch was being…

    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 · D2024-02-16 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    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 and systematically investigate an adverse event as part of their Quality Assurance and Performance Improvement (QAPI) meetings/plan for 1 (R59) of 17 residents reviewed for QAPI in the sample of 40. Findings Include: R59's Face Sheet documented R59 is a [AGE] year-old male, who admitted to the facility on [DATE] at 5:30 PM. Diagnoses listed on this document in their entirety are: Unspecified Dementia, Unspecified Atrial Fibrillation, Anxiety Disorder, Vitamin D Deficiency, Constipation, Dextrocardia, Essential (primary) Hypertension, Dorsalgia, and other Amnesia. V25 (Physician) is listed as being R59's Primary Care Physician. The only contacts listed for R59 on this document are V21 (Family Member & Power of Attorney/POA) and V22 (Family Member). R59's Minimum Data Set with an assessment reference date of 1/4/24 documented a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section E0900 documents 0,…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-16 · 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

    Based on observation, interview, and record review the facility failed to maintain infection control professional standards when completing wound care for one (R45) of seven residents reviewed for infection control out of a sample of 40. Findings include: 1. R45's face sheet documented an admission date of 5/5/22 with diagnoses including: unspecified dementia without behavioral disturbance, dysphagia, anxiety disorder, vitamin B12 deficiency, hemiplegia, atrial fibrillation. R45's Physician Orders List documented a 2/2/24 order . Cleanse area left 5th toe with normal saline (then) paint with betadine apply (calcium alginate) to wound bed cover with (absorbent bandage) do not use adhesive dressing wrap first with kerlix and then with coban for protection . On 2/9/24 at 9:49 AM V33 (Licensed Practical Nurse/ LPN) provided wound care for R45. V33 completed hand hygiene and donned gloves. V33 removed R45's left foot dressing. V33 changed her gloves but did not perform hand hygiene. V33 cleaned R45's wound with normal saline and painted with betadine. V33 changed her gloves but did not…

    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 · F2023-12-29 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review the facility failed to ensure preventative cleaning measures were implemented to promote pest control and maintain an environment free of insects. This failure has the ability to affect all 62 residents living at the facility. Findings include: On 12/27/23 at 11:40am, R4 was alert and oriented to person, place, time and purpose. R4 stated she has seen roaches in the facility dining room on her table within the past few weeks. On 12/28/23 at 8:50am, a roach was observed crawling on the floor of the Activity/Alternate Dining Room. On 12/28/23 at 9:00am, the facility kitchen was toured. V4, Cook, stated for past 2 to 3 weeks he has seen roaches in the dish room. The floor of the dish room was flooded with food debris under the garbage disposal. The dish room smelled of rotting food. V4 stated V5, Dietary Manager, and V1, Administrator, are aware of this issue. V4 stated it is his understanding is they are trying to get an exterminator to come to the facility. V4 stated the roaches are probably due to the disposal leaking and attracting…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-29 · 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, observation, and record review, the facility failed to ensure a resident was free from resident to resident abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 4. Findings include: A Facility Reported Incident document submitted to IDPH (Illinois Department of Public Health) dated 12/17/23 stated, It was reported at 10:00am on 12/17/23 that (R2) was attempting to wheel around R1 (in wheelchair) in the hallway when they began a verbal argument. As (R2) went around (R1), (R2's) wheelchair rolled over (R1's) toe. Residents were separated and nurse assessment completed on (R1's) toe, noting light bruising to big toe, attending physician and POA (Power of Attorney) notified. Orders received to x-ray (R1's) toe. Local police and Ombudsman notified. Investigation started. Final (investigation) will be sent in five days. R1's Face Sheet documented an admission date of 3/27/21 and diagnoses including Unspecified Dementia. R1's Nurse's Note dated 12/17/23 at 10:44am documents that (R1) allegedly ran over residents feet. Assessment made on resident 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-06 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately label insulin with resident's name and date of opening for 6 (R3, R7, R11, R14, R16, R37) of 12 residents reviewed for medication labeling and storage in a sample of 26. Findings include: On [DATE] at 10:10AM, the medication cart serving rooms 100 through 308 was observed to have 1 Novolog Flexpen with no name or open date, 2 of R14's Humalog Kwikpens with no open date, 1 Levemir Flextouch with no name or open date, 1 Humalog Kwikpen with no name or open date, 1 of R11's Basaglar pens with no date, 1 Lantus vial with no name or date, and 1 of R14's Lantus vials with no open date. V4 (Registered Nurse/RN) said all the insulins should be labeled with the resident's name and date of opening. R7's face sheet documented an admission date of [DATE] and diagnoses including: hypertension, heart failure, major depressive disorder. R7's Physician Order Sheet (POS) documented an [DATE] order for Lantus 100 unit/ ml (milliliter) 25 units…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to WLC MANAGEMENT FIRM — 18 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 →

RatingThis homeChain avg
Overall 3 of 52.8+0.2 vs chain
Health inspection 4 of 53.7+0.3 vs chain
Staffing 3 of 51.8+1.2 vs chain
Quality measures 1 of 51.5-0.5 vs chain
The other 17 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
WLC MANAGEMENT FIRM LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/01/2017
STOUT, SCOTTIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL100%since 07/01/2017

CMS files one row per role, so the 4 rows in the source record cover these 2 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.

$5.4M
Net patient revenuemost recent cost report
+2.4%
Operating marginrevenue minus expenses
$271K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 9%Other / private 19%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $271K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

$241per resident / day
operating cost
$7,325per month
≈ monthly operating cost
$247per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 145890. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.

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