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Farmington Village Nrsg

701 South Main Street, Farmington, IL 61531 · For profit - Limited Liability company · 92 certified beds · (309) 245-2408 Medicare & Medicaid certified

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Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited May 20261 immediate-jeopardy citation$73,577 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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
  • the CMS record shows $73,577 in federal fines (most recent 2026-05-01)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
158 E Fulton St · (309) 245-2416 · Call to confirm hours
Pharmacy
Walgreens8.9 mi
555 N Main St · (309) 647-7610 · Call to confirm hours
Grocery
1090 E Fort St · (309) 245-2122 · Call to confirm hours
Park
23352 E Park Rd · Typically dawn to dusk
Place of worship
156 E Vernon St · (309) 245-4001

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 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 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 4 to 5 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 rating5★
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 increased11.2%13.4%15.4%better
Long-stay residents who lose too much weight6.6%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder1.8%0.9%0.9%worse
Long-stay residents with a urinary tract infection0.4%1.5%2.0%better
Long-stay residents with depressive symptoms72.4%54.2%6.5%worse 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 injury1.4%3.1%3.3%better
Long-stay residents whose ability to walk worsened34.4%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication18.0%18.3%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers2.6%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control28.1%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table7.3%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine94.3%63.1%79.4%better
Short-stay residents rehospitalized after admission16.3%26.1%22.6%better
Short-stay residents with an outpatient ER visit4.4%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days0.922.021.67better
Long-stay outpatient ER visits per 1,000 resident days0.482.221.80better

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.

54.2% 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 106 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.2%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
25.0%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 25.0% 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 20 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 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF54.2%CMS range 45.3–61.851.5%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 8.2–15.710.7%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 discharge25.0%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 discharge10.0%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 discharge35.0%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 identified100.0%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%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 worsened0.0%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 hospitalization7.2%CMS range 3.8–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.401.02Oct 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

0.65
RN hours/ resident / day
0.82
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.63
Total nurse hours/ resident / day
0.36
RN hoursweekends
39.7%
Total nursing turnover
30.8%
RN turnover

How full it usually is: this home is certified for 92 beds and averages 82.9 residents a day — about 90% occupied, or roughly 9 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.07 hrs/resident/day on weekends vs 3.85 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.76 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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

18
deficiencies at the latest standard inspection (2026-05-01)
4
at the previous standard inspection (2025-05-29)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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 11 most serious are shown; the remaining 17 are one tap away and print in full.

  • Immediate jeopardy · J2026-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to accurately assess a resident for elopement risk, ensure adequate supervision, and develop and implement interventions to prevent a resident from eloping on multiple occasions for one of twenty-four residents (R65) reviewed for elopement in the sample of 64. These failures resulted in R65 exiting the building unsupervised on multiple occasions, creating a likelihood of serious injury, harm, or death and put R65 at risk for suffering falls with major injury, weather exposure, and getting lost without the ability to summon help.The Immediate Jeopardy began on 11/12/25 when R65 was inaccurately assessed as being at zero risk for elopement despite documented elopement-risk behaviors. V1/Administrator and V2/Director of Nursing were notified of the Immediate Jeopardy on 4/24/26 at 12:00 PM. The surveyor confirmed by observation, interview, and record review the Immediate Jeopardy was removed on 4/28/26 but noncompliance remains at Level Two because additional time is needed to evaluate the implementation 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-05-01 · 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 place use by dates on perishable foods. This failure has the potential to affect all 83 residents who reside in the facility. Findings include:The facility policy Storage of Dry Goods/Foods, undated, documents not in its entirety, Non-refrigerated foods, disposable dishware and other dry goods are stored in a clean, dry area which is free from contaminants.Opened products are labeled, dated with the use by date and tightly covered to protect against contamination including from insects and rodents. The facility policy Storage of Food and Supplies, undated, documents not in its entirety, Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with Use by date or expiration date.All foods will be covered, labeled, and dated. The facility policy Storage of Frozen foods, undated, documents, If taken out of original container, food is tightly wrapped and labelled with the name of the item and the use by date. On 4/21/26 at 9:18 AM, initial tour of kitchen with the following…

    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 · F2026-05-01 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to perform Antibiotic Stewardship duties and fully utilize the Facility adopted McGeer's criteria for antibiotic use and education. This failure has the potential to affect all 83 residents that currently reside in the facility.Findings Include: The Facility's Antibiotic Stewardship Program policy dated 4/29/2025 documents The purpose of antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance.The Facility's Antibiotic Stewardship Program policy dated 4/29/2025 documents Education: The facility will provide resources to clinician, nursing staff, residents, and families about resistance and appropriate antibiotic use. The facility will utilize McGeer's criteria when considering initiation of antibiotics. The facility will work with the hospital and the attending physician's order for a course of antibiotics to validate criteria…

    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 · F2026-05-01 · tag F0940 — failed to train staff — widespread
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    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, implement and maintain an effective training program for all staff and determine the amount of time and the types of training necessary to meet the residents' needs. This failure has the potential to affect all 83 residents residing in the facility.Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, were reviewed. The Census Roster documents 83 residents reside in the facility.The Facility assessment dated [DATE] documents Staff Training and Competency- The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care and services to the identified population. The Assessment does not include the amount of time and the types of training necessary to meet the resident's needs.On 4/24/26 at 2:00 PM, V1 (Administrator) stated that during the monthly staff meetings they provide in-service education and training. V1 stated…

    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 · F2026-05-01 · tag F0941 — widespread
    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
    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 all staff received mandatory training and education related to effective communication. This failure has the potential to affect all 83 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, were reviewed. The Census Roster documents 83 residents reside in the facility.The Facility assessment dated [DATE] documents Staff Training and Competency- The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care and services to the identified population. The Assessment does not include the amount of time and the types of training necessary to meet the effective communication training requirement.On 4/24/26 at 2:00 PM, V1 (Administrator) stated that during the monthly staff meetings they provide in-service education and training. V1 stated the monthly staff education tracking sheet has…

    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 · F2026-05-01 · tag F0942 — widespread
    Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
    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 all staff received mandatory training and education related to rights of the residents and responsibilities of the facility to care for its residents. This failure has the potential to affect all 83 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, were reviewed. The Census Roster documents 83 residents reside in the facility.The Facility assessment dated [DATE] documents Staff Training and Competency- The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care and services to the identified population. The Assessment does not include the amount of time and the types of training necessary to meet the rights of the residents and responsibilities of the facility to care for its residents training requirement.On 4/24/26 at 2:00 PM, V1 (Administrator) stated that during 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-05-01 · tag F0943 — widespread
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    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 all staff received mandatory training and education on abuse, neglect and exploitation including activities which constitute abuse, neglect and exploitation, procedures for reporting incidents, dementia management and abuse prevention. This failure has the potential to affect all 83 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, were reviewed. The Census Roster documents 83 residents reside in the facility.The Facility assessment dated [DATE] documents Staff Training and Competency- The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care and services to the identified population. The Assessment does not include the in-service/competency training to meet the abuse, neglect and exploitation including activities which constitute abuse, neglect and exploitation,…

    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 · F2026-05-01 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement 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 interview and record review, the facility failed to ensure all staff received mandatory training and education on the elements and goals of its Quality Assurance Performance Improvement program. This failure has the potential to affect all 83 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, were reviewed. The Census Roster documents 83 residents reside in the facility.The Facility assessment dated [DATE] documents Staff Training and Competency- The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care and services to the identified population. The Assessment does not include specific in-service/competency training to meet the elements and goals of its Quality Assurance Performance Improvement program training requirements.On 4/24/26 at 2:00 PM, V1 (Administrator) stated that during the monthly staff meetings they provide…

    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 · F2026-05-01 · tag F0945 — failed to train staff on abuse prevention — widespread
    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the 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 interview and record review, the facility failed to ensure all staff received mandatory training and education for the Infection Prevention and Control program which includes the written standards, policies and procedures for the program. This failure has the potential to affect all 83 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, were reviewed. The Census Roster documents 83 residents reside in the facility.The Facility assessment dated [DATE] documents Staff Training and Competency- The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care and services to the identified population. The Assessment does not include specific in-service/competency training or topics to meet the Infection Prevention and Control program which includes the written standards, policies and procedures for the program requirements.On 4/24/26 at 2:00…

    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 · F2026-05-01 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    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 Certified Nursing Assistants (CNAs) were provided and completed a minimum of 12 hours of in-service training per year. This failure has the potential to affect all 83 residents residing in the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, were reviewed. The Census Roster documents 83 residents reside in the facility.The Facility assessment dated [DATE] documents Staff Training and Competency- The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care and services to the identified population. The Assessment does not include specific in-service/competency training and topics or how the Certified Nurse Aides required 12-hours of training will be conducted.The 2025 Certified Nurse Aide In-service Tracking Sheet with the name of the topics covered monthly documents 42 Certified Nurse Aides did not meet…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-05-01 · tag F0949 — failed to train staff on dementia and abuse — widespread
    Provide behavior health training consistent with the requirements and as determined by a facility 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 all staff received mandatory training and education related to Behavioral Health. This failure has the potential to affect all 83 residents residing within the facility.Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 4/21/26, were reviewed. The Census Roster documents 83 residents reside in the facility.The Facility assessment dated [DATE] documents Staff Training and Competency- The facility in-service training calendar indicates the mandated annual training requirements as well as specific topics pertinent to provision of care and services to the identified population. The Assessment does not include specific in-service/competency training or topics to meet the Behavioral Health training requirements.On 4/24/26 at 2:00 PM, V1 (Administrator) stated that during the monthly staff meetings they provide in-service education and training. V1 stated the monthly staff education tracking sheet has topics listed…

    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
Show the remaining 17 citations
  • Potential for harm · E2026-05-01 · 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 safely store medications for two (R28, R71) of nineteen residents reviewed for medication administration. The facility also failed to assure a medication cart was locked when not attended, this failure has the potential to affect all 31 (R1, R5, R7, R9, R11, R12, R14, R23, R24, R26, R28, R31, R34, R35, R36, R41, R44, R48, R51, R52, R54, R58, R63, R64, R66, R69, R71, R80, R81, R83, R85) residents that reside on the 200 hall. Findings include:The facility policy, Storage of Medications, dated 10/25/2014, documents not in its entirety, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications. Medication rooms,…

    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 · D2026-05-01 · 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 resident care plans were updated and accurately reflected residents' current code status and advanced directive wishes consistent with signed Practitioner Order for Life-Sustaining Treatment (POLST) forms for two (R3 and R65) of 24 residents reviewed for advanced directives in the sample of 64.Findings include:The facility's Advanced Directive and Advanced Care Planning/POLST (Physician's Order for life Sustaining Treatment) Guideline, dated [DATE], includes: the objective of this guideline is to establish a facility practice to educate and inform the residents of their rights, promoting the residents their rights to accept or refuse medical or surgical treatment and to formulate an advanced directive in assisting the resident to exercise his/her rights. Changes to the resident choices for advanced directives will be documented, included in the resident plan of care, specific documents will be updated as necessary, physician orders will be…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-01 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 psychotropic medications had proper indications for use and failed to use nonpharmacologic interventions other than psychotropic medication for three residents (R1, R2, R56) of five residents reviewed for unnecessary medications in a total sample of 64.Findings Include: The Facility's undated Psychotropic Medications policy documents This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition is diagnosed by the attending physician or psychiatric consult. Chemical Restraints shall not be used to discipline a resident or for staff convenience, but only in accordance with the physician's orders when other interventions have proven unsuccessful, as documented in the medical record. The Facility's undated Psychotropic Medications policy documents The following specific conditions are acceptable to warrant the use of antipsychotic medications and one of these…

    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 · D2026-05-01 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who depend on staff's assistance for Restorative Care services received care as ordered for four of four residents (R6, R8, R16, R18 R43) reviewed for Restorative Care, in a sample of 64. Findings include:The Restorative Nursing Policy, not dated, documents each resident will be assessed for restorative/rehabilitative needs and placed in nursing director programs. Each program is directed toward assisting residents to achieve and maintain optimal levels of self-care and independence, thus enhancing self-esteem, promoting active participation in daily living and improving quality of life. This ensures that each resident's individual rehabilitative needs are identified, and appropriate nursing measures are implemented to achieve a maximum level of independence. Restorative Nursing Programs include range of motion and walking. Restorative services and the resident's response toward goals will be documented as follows by staff…

    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 · D2026-05-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and changed gloves when providing urinary catheter care and maintained a urinary catheter bag off the floor for one (R32) of three residents reviewed for urinary catheters in the sample of 64 residents. Findings include:The facility's policy for Urinary Care, Catheter, dated January 2016, includes the purpose of the procedure is to prevent catheter-associated urinary tract infections. Following aseptic insertion of the catheter, maintain a closed drainage system. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment, as ordered. Use Standard Precautions when handling or manipulating the drainage system. Use clean technique when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor. The facility's Catheter Care - Foley Catheter…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-01 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer bedtime snacks to three of three diabetic residents (R4, R6, R43) reviewed for bedtime snacks in the sample of 64.Findings include: The Snack Protocol policy, not dated, documents snacks are available to all residents during and after kitchen operation hours. Dietary will provide appropriate snacks based on diet order.1. R4 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Atrial Fibrillation, Chronic Congestive Heart Failure, Polyarthritis and Muscle Wasting and Atrophy.The Brief Interview for Mental Status (BIMS) documents R4 is cognitively intact.R4's current care plan documents R4 is at risk for Malnutrition, is an insulin dependent diabetic and is at risk for hypo/hyper glycemic episodes.R4's Vital Signs report includes diet and snack intakes dated 4/6/26 through 4/24/26 and does not indicate snacks were provided/offered or consumed.On 4/21/26 at 2:40 PM and on 4/22/26 at 11:30 AM, R4 stated nighttime snacks are not offered…

    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 · D2026-05-01 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an accurate medical record for three of three residents (R6, R8, R43) reviewed for accuracy of medical records, in a sample of 64. Findings include:The Restorative Nursing Policy, not dated, documents restorative services and the resident's response toward goals will be documented as follows by staff implementing the plan on one or more of the following forms: Restorative Documentation Record, Nursing Progress Notes, ADL (Activities of Daily Living) Record and/or Treatment Administration Record.The Range of Motion Exercises (ROM) policy, not dated, documents the following information should be documented in the record: date and time exercises were conducted, name and title of who performed the procedure, type of ROM exercises given, how long the exercises were conducted, the signature and title of who recorded the data.1. R6 was admitted on [DATE] with diagnoses of Polyneuropathy, Type 2 Diabetes Mellitus, Small Cell-B Cell Lymphoma, Chronic…

    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 · Fcited before2025-05-29 · 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 interview, observation and record review, the facility failed to ensure opened items in the kitchen were dated when opened and dry food items were stored in an airtight container. These failures have the potential to affect all 83 residents residing in the facility. Findings include: The facility's Storage of Dry Goods/Foods policy (undated) documents, Opened products are labeled, dated with the use by date and tightly covered to protect against contamination including insects and rodents. This policy also documents, Plastic containers with tight-fitting lids will be used for storing flour, sugar, bulk cereal, dried vegetables, etc. On 05/27/25 at 10:30 AM, a tour of the kitchen was completed with V12 (Dietary Manager). At 10:35 AM in the dry storage area, the following items were found to be open and were not labeled with the date when opened: a large bag of yellow cake mix; a large bag of cornbread mix; a large bag of waffle mix; a large bag of buttermilk biscuits, a large bag of pudding and pie filling; a large bag of graham cracker crumbs; two bags of strawberry gelatin…

    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 · E2025-05-29 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    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 ensure sufficient seating was available to accommodate residents who chose to eat in the dining room. This failure affected R1, R4, R6, R9, R10, R15, R19, R24, R30, R62, R68, R74, R230 and R305 reviewed for resident rights. Findings include:On 05/27/25 at 12:10 PM, Seven residents, R1, R6, R9, R19, R74, R230 and R305, were sitting in their wheelchairs at the entrance to the dining room watching other residents seated at dining tables eat lunch. R230 stated, We (residents) are waiting for a spot to open up so we can eat lunch. It'll be an hour before we can eat.On 05/27/25 at 12:15 PM, V4 (Certified Nursing Assistant) stated, The residents (R1, R6, R9, R19, R74, R230 and R305) who are waiting in the front of the dining room must wait to eat. They must wait until a seat at a table opens up once a resident finishes eating. There are a few that have to wait to eat because there are not enough seats available for everyone at once.On 05/27/25 at 12:20 PM, V9 (Licensed Practical Nurse/Staff Educator) stated there are…

    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 · D2025-05-29 · 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

    Based on Observation, Interview and Record review, the facility failed to thoroughly cleanse around a wound leaving fecal matter at the exterior boarder of a wound for one of one resident (R72) reviewed for pressure ulcers in the sample of 37. Finding Include: The facility's Dressing Non-Sterile (Aseptic) policy, dated January 2017, documents, The purpose of this procedure is to provide guidelines for the application of non-sterile dressings. Clean or irrigate area/wound with solution specified in treatment order (normal saline, wound cleanser, etc.) Pat peri wound and wound dry using dry gauze. R72's Wound Order documents, Cleanse area to sacrum with (wound cleanser), pack wound with wound cleanser soaked in gauze, cover with ABD (abdominal pad) and secure with tape once daily and as needed for soiling. On 5/28/2025 at 9:25 AM, V6 (Wound Nurse) and V8 (CNA/Certified Nursing Assistant) prepared to perform wound care for R72's sacral pressure ulcer. A pressure wound was present measuring 6.2 cm (centimeters) wide, 4.5 cm long and 1.5 cm deep. The sacral wound contained grey/black…

    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 · D2025-05-29 · 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 implement Enhanced Barrier Precautions while providing cares to a resident with a central line for one of one resident (R6) reviewed for Enhanced Barrier Precautions in the sample of 37. Findings include: The facility's Enhanced Barrier Precautions Policy dated 01/2025 documents, Enhanced Barrier Precautions (EBP) is designed to reduce transmission of Multi-Drug Resistant Organisms (MDROs) and Extensively Drug-Resistant Organisms (XDROs) in nursing homes. It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a MDRO multi-drug resistant organism such as a resident with wounds, indwelling medical devices, or residents with infection or colonization with a an MDRO or XDRO. Procedure: 1. Standard precautions should always be applied to all residents at all times. 2. In addition to Standard Precautions residents will be…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-04-05 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to notify, in writing, and maintain a copy in the Medical Record for notification of Resident/Resident Representatives upon Transfer/Discharge that were reviewed for Bed Hold Transfers. This failure has the potential to affect all 75 Residents residing in the Facility. Findings include: Facility Census and Condition Report, dated 4/2/24, documents 75 Residents residing in the Facility. Facility Bed Hold readmission Policy, dated 11/2016, documents: it is the policy of this Facility to readmit Residents after hospitalization or temporary therapeutic leave when the Resident requires services which can be provided by the Facility; this may be accomplished by holding a specific bed or by making available the next semi-private accommodations in the event a Resident does not desire to hold the specific bed; Residents, or their Designated Representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours; the Facility provides…

    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 · F2024-04-05 · tag F0625 — widespread
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to notify, in writing, and maintain a copy in the Medical Record for notification of Resident/Resident Representatives upon Transfer/Discharge that were reviewed for Bed Hold Transfers. This failure has the potential to affect all 75 Residents residing in the Facility. Findings include: Facility Census and Condition Report, dated 4/2/24, documents 75 Residents residing in the Facility. Facility Bed Hold readmission Policy, dated 11/2016, documents: it is the policy of this Facility to readmit Residents after hospitalization or temporary therapeutic leave when the Resident requires services which can be provided by the Facility; this may be accomplished by holding a specific bed or by making available the next semi-private accommodations in the event a Resident does not desire to hold the specific bed; Residents, or their Designated Representative, shall be informed of this policy at the time of admission and at the time of transfer to a hospital, or for therapeutic leave which extends beyond 24 hours; the Facility provides…

    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 · D2024-04-05 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review the facility failed have a valid PASRR (Pre-admission Screening and Resident Review) for one resident (R49) of three reviewed for PASSR in a total sample of twenty-three. Findings Include: The Facility's undated PASRR (Pre-admission Screening and Resident Review) Guideline documents the objective of the PASSR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASRR will be evaluated annually and upon any significant change for those individuals identified, R49's Pre-admission Screening and Resident Review/ Level 1 Screen dated [DATE] documents Convalescence Category with no required services. R49's PASSR dated [DATE] also documented Approval Period: 60 days. On [DATE] at 9:00 AM V1 (Administrator) confirmed that R49's Pre-admission Screening and Resident Review validity expired on [DATE] and should have been redone.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · 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 observation, interview, and record review, the facility failed to develop a care plan to include a biliary drain and a skin condition for two (R33, R42) of 18 residents reviewed for care plans in a sample of 23. Findings include: Facility Care Plans policy, updated October 2022, documents An individualized Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. Facility Skin and Wound Management policy, revised 10/2019, documents The presence of skin impairment should be denoted on the person-centered plan of care. 1. R33's physician orders, dated 2/02/2024, documents Cleanse biliary drain site with wound cleanser, cover with split sponge. Change daily and as needed for soiling. Monitor Biliary Drain Site every shift for signs and symptoms of infection. R33's nurses notes, dated 2/2/24, documents (R33) returned on 2/02/2024 at 4:02 PM. Resident has right biliary drain site. On 4/02/24 at 11:00 AM and 4/3/24 at 9:33 AM, R33 was and alert sitting in a manual…

    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 · D2024-04-05 · 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 — the official record, unedited, may be distressing

    Based on observation, record review and interview, the facility failed to revise a plan of care for 1 of 4 (R26) residents reviewed for indwelling catheters in a total sample of 23. Findings Include: Facility Care Plans policy, updated October 2022, documents An individualized Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. On 4/2/2/24 at 9:38 AM R26 was in his room and did not have an indwelling catheter. R26's Physician Orders dated March 2024 did not have an order for an indwelling catheter. R26's current Care Plan dated 03/05/24 lists an indwelling catheter as an area of care. On 04/03/24 at 2:34 PM, V4, Care Plan Coordinator, confirmed R26 does not have an indwelling catheter but his Care Plan states he does.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-05 · 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 observation, interview, and record review, the facility failed to have orders and follow up on a dermatology order for one (R42) of one resident reviewed for skin conditions in a sample of 23. Findings include: Facility Skin and Wound Management policy, revised 10/2019, documents To ensure appropriate assessment, treatment, monitoring and documentation of skin and skin alteration. The presence of skin impairment should be denoted on the person-centered plan of care. R42's Wound Evaluation and Management Summary, dated 3/5/24, documents Recommend referral to Dermatology. R42's physician orders, dated 3/15/24, documents Appointment with (local) Clinic Dermatology. Possible skin cancer under left eye. R42's physician orders for March and April 2024 have no orders regarding R42's left under eye skin concern. R42's TAR/Treatment administration record or MAR/Medication administration record for March and April 2024 do not have any orders/documentation for R42's left under eye skin concern. On 4/02/24 at 10:46 AM, R42 was sitting in his electric recliner and under his left eye 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

“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

$73,577 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $73,577 — penalty dated 2026-05-01
  • Medicare payment denial — starting 2026-05-26 for 16 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ATIED ASSOCIATES — 12 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 2 of 51.8+0.2 vs chain
Health inspection 1 of 52.2-1.2 vs chain
Staffing 2 of 51.8+0.2 vs chain
Quality measures 5 of 53.2+1.8 vs chain
The other 11 homes this chain runs (chain average 1.8★, 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
RAY, SHERWINIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF30%since 01/13/2025
VASS, JACOBIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/26/2023
ATIED ASSOCIATES LLCOrganizationADP OF THE SNFsince 01/13/2025
EXTENDED CARE CLINICAL LLCOrganizationADP OF THE SNFsince 05/01/2022
EXTENDED CARE CONSULTING LLCOrganizationADP OF THE SNFsince 05/01/2022
ROTH & CO, LLPOrganizationADP OF THE SNFsince 01/08/2025
MARTIN, ERINIndividualADP OF THE SNFsince 05/01/2022

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$8.0M
Net patient revenuemost recent cost report
+2.1%
Operating marginrevenue minus expenses
$1.0M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 50%Medicare 11%Other / private 39%

This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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

$293per resident / day
operating cost
$8,911per month
≈ monthly operating cost
$299per 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 145404. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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