No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Frankfort Terrace

40 North Smith, Frankfort, IL 60423 · For profit - Corporation · 120 certified beds · (815) 469-3156 Medicaid only — no Medicare

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20251 immediate-jeopardy citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (21% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 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
20325 S Graceland Ln Ste A · (815) 469-6909 · Call to confirm hours
Pharmacy
21000 S Frankfort Square Rd Ste M · (815) 534-5813 · Call to confirm hours
Grocery
19818 S Harlem Ave · (779) 324-5108 · Call to confirm hours
Park
(815) 469-9400 · Typically dawn to dusk

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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 increased10.9%13.4%15.4%better
Long-stay residents who lose too much weight4.4%6.3%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.9%0.9%better
Long-stay residents with a urinary tract infection0.5%1.5%2.0%better
Long-stay residents with depressive symptoms99.2%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 injury1.9%3.1%3.3%better
Long-stay residents whose ability to walk worsened5.7%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication11.1%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers0.0%4.8%4.7%check this — see note marked star below the table
Long-stay residents with worsening bladder/bowel control9.6%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table84.4%21.7%17.1%check this — see note marked dagger below the table
Short-stay residents given the seasonal flu vaccine42.9%63.1%79.4%worse
Long-stay hospitalizations per 1,000 resident days0.852.021.67better
Long-stay outpatient ER visits per 1,000 resident days0.832.221.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

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.

Staffing

0.66
RN hours/ resident / day
0.14
LPN hours/ resident / day
1.06
Aide hours/ resident / day
1.86
Total nurse hours/ resident / day
0.59
RN hoursweekends
20.8%
Total nursing turnover
15.8%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 107.8 residents a day — about 90% occupied, or roughly 12 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 1.86 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.06 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 1.59 hrs/resident/day on weekends vs 1.97 on weekdays — 19% thinner on weekends. RN hours go from 0.68 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 21% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

11
deficiencies at the latest standard inspection (2024-06-07)
9
at the previous standard inspection (2023-06-20)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Immediate jeopardy · Lcited before2023-06-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
    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 secure hazardous chemicals in a locked storage area in accordance with the facility policy. There were 96 ambulatory residents, all with psychiatric illness with access to the hallway where the chemicals were stored. This failure presented a serious health risk to all 96 residents residing in the facility. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on June 14, 2023, when hazardous chemicals were observed in an unsecured hallway during the environmental tour. On June 14, 2023, at 12:48 PM with V16 (housekeeping supervisor) hazardous chemicals were observed in an unsecured hallway that leads to the kitchen and laundry room. The hallway has an unsecured door with direct access to the main dining room where ambulatory residents gather for meals and activities. The ambulatory residents can easily access the unlocked door and enter the hallway where the chemicals are being stored. V16 staed that t there was no room in the locked storage area to secure the hazardous chemicals. V1…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-10 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    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 a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental temperatures in a sample of 7. Based on observation, interview and record review the facility failed to maintain a comfortable environment. This applies to 4 of 6 (R1, R2, R4, R6) residents reviewed for elevated environmental temperatures in a sample of 7.Findings include. On 7/9/25 at 12:37 PM, residents were interviewed during lunch service. R1 stated she is hot everywhere she goes, and her room is very warm. R1 stated she was provided with a fan, but it is not sufficiently cooling her room. R1 stated the lobby and staff offices are cool. R2 stated her room was too hot and she was not provided with a fan. R4 stated the dining room temperature was comfortable, but her room was too warm. R6 stated only the dining room was comfortable. On 7/9/25 at 2:42 PM, room temperatures were taken with V6 (Maintenance Director). R1's room temperature with a fan was 81.8 degrees F (Fahrenheit). R2's room…

    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 · D2025-06-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This applies to 1 of 5 residents (R2) reviewed for abuse in the sample of 6. The findings include: R1's EMR (electronic medical records) showed that he was admitted on [DATE], and discharged on May 26, 2025, with diagnoses including schizoaffective disorder, depressive type, hypertensive heart disease without heart failure, cocaine abuse, unspecified with withdrawal, alcohol abuse, uncomplicated, peptic ulcer site unspecified, unspecified as acute or chronic, without hemorrhage or perforation, hypo-osmolality and hyponatremia, other poly osteoarthritis. R1's quarterly MDS (minimum data set) dated April 28, 2025, showed that R1 was moderately impaired in cognition. FRI (Facility Reported Incident) report included the following: Date/time of incident: May 26, 2025, 12:45 PM. Final Report sent to IDPH (Illinois Department of Public Health) on May 30, 2025. Brief description 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the kitchen and use proper sanitation while checking food temperatures. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/4/24 documents that the total census was 101 residents. On 6/4/24 at 10:49 AM, V9 (Dietary Manager) said there are no NPO (Nothing by Mouth) residents. All 101 residents eat from the facility kitchen. On 6/4/24 starting at 10:00 AM, the facility kitchen was toured in the presence of V9 (Dietary Manager) and the following was found: In the dry storage room refrigerators: 1. An opened bag of shredded lettuce, not labeled or dated with browning lettuce and yellow liquid in the bottom of the bag. 2. A bag of unlabeled and undated diced meat with yellow liquid in…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-06-07 · tag F0880 — failed to prevent and control infections — widespread
    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 interview and record review the facility failed to implement and document measure that prevent the waterborne pathogen Legionella and provide an up-to-date infection control policy. \This applies to all 101 residents that resided in the facility. Findings include: On 6/6/24 at 12:48 PM, V4 Maintenance Director stated corporate is responsible for testing for legionella and would have the reports. V4 stated he never heard of legionella. V4 stated each wing has hot water heater. V4 stated the last time he checked water temperatures was in March 2024. V4 stated he wasn't documenting because there were problems with the water heaters giving accurate temperatures. V4 Maintenance Director stated the resident and staff would tell him when the water temperatures dropped to make sure it was up to par. On 6/6/24 at 2:09 PM, V1 Administrator stated the facility uses well water and city tests the water for legionella. V1 stated water temperatures should be tested daily so if there is a problem, we know about it. On 6/6/24 at 3:00 PM V1 Administrator stated there is no infection control…

    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 · F2024-06-07 · tag F0919 — failed to provide a working call system — widespread
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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 a fully functioning call light system. This applies to all residents residing at the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/4/24 documents that the total census was 101 residents. On 06/04/24 at 11:13 AM, R92 was observed in her room and R92 said that she turned her call light on for staff to come down to put her brace on and nobody came down. At 11:24 AM R92 turned her call light on again. R92 said, I told my case manager that it is hard to get a CNA (Certified Nurse's Assistant) to come down to my room to help me. I feel I should get the same help as everyone else, and I don't. R92 was observed crying as she was speaking. At 11:31 AM the surveyor went to the nurses' station where the call light board was located and saw that R92's call light was on but not alarming. At that time V11 MDS (Minimum Data Set) Coordinator was observed in the nurse's station making the first…

    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 · Ecited before2024-06-07 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, & record review, the facility failed to provide ADL care (activities of daily living) to 4 0f 4 residents dependent of ADL care (R3, R42, R83 & R92) in a sample of 28. Findings include: 1. On 06/05/24 at 11:07 AM R3 was observed with facial hair on her chin. R3 stated that she did not know the last time she was shaved and that she wanted the staff to shave her. R3's electronic health record showed that she is an [AGE] year-old female admitted to the facility with diagnoses including paranoid schizophrenia, scoliosis, spinal stenosis, and polyosteoarthritis. R3's 5/1/24 MDS (Minimum Data Set) Section GG - personal hygiene showed that R3 is dependent on staff for care. A review of R3 electronic health records was conducted on 06/06/24 at 1:40 PM and it showed under Task GG- Personal Hygiene - no documentation for the last 6 months. R42's 30 day look back for Behavior Monitoring and Interventions from 5/8/24 - 6/6/24 showed no behaviors observed and the 30 days look back for ADL…

    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 · D2024-06-07 · 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 invite residents to their interdisciplinary care plan meeting. This applies to 2 of 2 residents (R21 and R76) reviewed for care planning in a sample of 28 residents. Findings include: 1. R21 admitted to the facility on [DATE]. R21 has diagnoses that includes schizophrenia, venous insufficiency, gastro-esophageal reflux disease, hypertensive heart disease, hyperlipidemia, peripheral vascular disease, osteoarthritis, scoliosis, osteoporosis, and bipolar disorder. R21 MDS (Minimum Data Set) dated 5/1/24 shows she is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. R21's care plan dated 5/13/24 states the residents demonstrate strong activity participation as evidence by joining a variety of group programs, actively participating in, and supporting resident council. On 6/6/24 at 10:45 AM, R21 stated she did not remember the last time she was invited to a care plan meeting. 2. R76 readmitted to the facility on [DATE]. R76 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-07 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow a physician's order for 1 resident (R92) in a sample of 27. Findings include: R92 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including schizophrenia, type 2 diabetes & osteoarthritis. On 06/04/24 at 11:13 AM, R92 was observed in her room with no braces on her wrist. There were 2 braces observed on her chair in her room at that time. R92 stated she wears braces on her wrists, but no one will come to help her to put it on. R92 stated, I can't put it on myself. The CNAs (Certified Nurse's Assistants) don't come to help put it on. I feel I should get the same help as everyone else, and I don't. R92 was observed crying as she was speaking. R92 said They know I have to wear the braces every day and that they are to put them on me, and they don't come. R92's 3/7/24 MDS section C showed that R92 cognition is intact & section GG Personal Hygiene showed that R92 needs substantial to maximal assistance. On…

    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 · D2024-06-07 · 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 adaptive eating utensils to a resident with upper extremity impairments. This applies to 1 of 1 resident (R5) reviewed for adaptive utensils. The findings include: R5 a [AGE] year-old admitted to the facility on [DATE] with multiple diagnoses which included dementia with behavioral disturbance, pressure ulcer of right buttock, diabetes, hypertensive heart disease, epilepsy, peripheral vascular disease, intellectual disabilities, schizophrenia, chronic obstructive pulmonary disease, and polyosteoarthritis per the face sheet. R5's MDS (Minimum Data Set) dated 03/22/24 showed R5 was cognitively impaired. The same MDS showed R5 had impairments to both upper and lower extremities. On 06/04/24 at 1:05 PM R5 was sitting in the dining room, at the table. R5 was being fed a mechanical soft diet by V16 (Certified Nursing Assistant). R5's meal card provided by the dietary department showed R5 was supposed to have a special spoon with meals.…

    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 · D2024-06-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to contain respiratory equipment for 2 residents (R38 & R42) in a sample of 27. 1. On 06/04/24 at 11:00 AM R38's BIPAP (bilevel positive airway pressure) mask and O2 nasal cannula was observed not covered. R38 said I use my BIPAP ever night and the oxygen as needed. R38's electronic medical record showed that she has diagnoses including chronic obstructive pulmonary disease with acute exacerbation, asthma & sleep apnea. R38's 2/19/23 physician order showed, oxygen as needed for COPD (chronic obstructive pulmonary disease), & 12/19/23 Physician order showed, BIPAP at night at bedtime for COPD. 2. On 06/04/24 10:36 AM R42's CPAP mask (continuous positive airway pressure) and O2 nasal cannula was observed not covered. R42 stated, I use my CPAP every night at 10pm. R42's electronic health record showed that R42 has diagnoses including chronic respiratory failure and obstructive sleep apnea. R42's 6/11/23 physician's order showed oxygen as needed via nasal cannula at 2 liters per minute. R42's 6/11/23 physicians…

    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 · Dcited before2024-06-07 · tag F0761 — failed to label and store drugs safely — isolated
    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 store and label medications properly. This applies to 1 of 1 resident (R48) reviewed for medication storage in the sample of 28. The findings include: On 06/05/24 at 9:00 AM The medication storage cabinet located inside of the nursing office contained a clear storage bag. R48 had three medications stored in the bag. The medications included: 1) Terconazole Cream 0.4% with directions to insert one applicator vaginally at bedtime until 06/01/24. The cream did not have a cap on it, and there was one applicator left in the box. 2) Ketoconazole shampoo 2% and 3) Albuterol Sulfate 0.083%. The medications were not stored in separate bags. The clear storage bag was not labeled. On 06/05/24 at 9:15 AM V2 (Director of Nursing) stated R48's vaginal medication was completed on 06/01/24 but the shampoo and nebulizer solution were still an active order. V2 stated the vaginal medication should not be stored with any other medications. V2 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-07 · tag F0800 — isolated
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary 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 interview and record review the facility failed to respect residents' right to make choices about their diet. This applies to 3 of 3 residents (R47, R57 and R101) in a sample of 28 residents. Findings include: On 6/4/24 at 12:43 PM during lunch resident were observed eating a plain turkey burger with cheese, a few tater tots, and a cup of shredded pineapple. 1. R47 admitted to the facility on [DATE]. R47 has diagnoses that includes schizophrenia, prediabetes, iron deficiency anemia, obesity, hypertensive heart disease and bipolar disorder. R47's current Physician order is no added salt diet regular thin liquids, milk with all meals per resident's request. R47's physician orders do not include a caloric limit or order limiting food intake. R47's MDS (Minimum Data Set) dated 5/21/24 shows he is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15. On 6/4/24 at12:43 PM, R47 stated he is not given extra food when he asks for it. R47 stated residents aren't allowed extra food unless…

    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 · D2024-06-07 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide mental health rehabilitation services to a resident identified with a serious mental health condition. This applies to 1 of 1 resident (R74) reviewed for mental health rehabilitative services in the sample of 28. The findings include: On 06/04/24 at 10:31 AM R74 was lying in bed. R74 stated she does not attend group meetings. R74 stated she doesn't do much since she does not attend group. R74 stated the staff does not try to encourage her to go to group. On 06/05/24 at 4:15 PM R74 was lying in bed. R74 stated she did not attend any group sessions today. R74 said no one invites her to groups, and she does not know the dates or times they are held. R74 said if she was invited to groups, she would attend. On 06/06/24 at 9:14 AM R74 continued to be lying in the bed. R74 said since the facility does not offer her anything to do, she lays in the bed and sleeps all day. R74 said she seldom attends activities, and no staff members comes 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-06-20 · 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 foods are stored and the dishes washed in a sanitary manner. This applies to all 105 residents who receive foods prepared in the facility kitchen. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated June 12, 2023, showed the facility census is 105. Facility gave verbal confirmation all 105 residents receive oral diets. On June 12, 2023, at 10:13 AM, during initial tour of facility kitchen, the freezer (#1) inside the kitchen was noted to be packed from floor to ceiling of the freezer with cardboard boxes containing frozen foods allowing no air circulation in between. Some of boxes had condensation on them and the outside temperature gauge showed 50 degrees Fahrenheit. There was no visible temperature gauge inside the freezer. The outside door surface of the freezer had extensive dried drippings. V4 (Dietary Manager) stated the delivery just came in and the door was kept open as they are in the process of stocking and arranging the items came in. V4 also…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-20 · 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

    Based on observation, interview and record review, the facility failed to label and date medications after it was opened to determine expiration dates. This applies to 8 of 10 residents (R9, R15, R35, R40, R51, R71, R72, R103) reviewed for labeling and storage of medications. The findings include: On 6/13/23 at 2:54 PM, the 3 morning medication carts and refrigerator (used for medication storage) were inspected with V12 (Nurse). The following medications were in the medication carts and observed as follows: 1. R71's Combivent Respimat 20 mcg/100 mcg per actuation was open and not dated. 2. R103's Combivent Respimat 20 mcg/100 mcg per actuation was open and not dated 3. R51's Latanoprost ophthalmic solution 0.005% opened 3/29/23. 4. R40's two bottles of Latanoprost 0.005% was open and not dated. 5. R35's Latanoprost 0.005% 125 mcg/2.5 ml was open and not dated 6. R72's Breo Ellipta 100-25 was open and not dated. 7. R15's Advair Diskus was open and not dated. 8. R9's Spiriva Respimat 2.5 mcg per actuation was open and not dated. On 6/14/23 at 1:23 PM, V2 (Director of Nursing/DON)…

    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 · Ecited before2023-06-20 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to serve portion sizes for regular and pureed diets as shown on the diet extension spreadsheet. This applies to 10 of 10 residents (R38, R50, R55, R72, R74, R85, R90, R96, R99, R103) reviewed for dining in the sample of 28. The findings include: 1. On June 12, 2023 at 10:13 AM during initial tour of kitchen, V4 (Dietary Manager) stated that the facility is serving breaded fish squares for lunch as that was what was sent by the food vendor. Facility daily spreadsheet for week 4, Monday lunch meal showed [NAME] Montreal (1 portion=3 oz/ounce protein) and the protein portion should be 3 ounces. On June 12, 2023 at 12:35 PM, during lunch meal service R38, R55, R72, R85, R90, R96, R99 and R103 received the above breaded fish squares served inside a bun. On June 12, 2023 at 12:57 PM, V4 weighed one piece of breaded fish with breading removed. The amount of editable protein was noted to be 2 oz per fish square leaving residents short 1 ounce 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-06-20 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    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

    Based on observation, interview and record review, the facility failed to follow the recipe to serve consistencies as shown for pureed and mechanical soft rice. This applies to 6 of 6 residents (R3, R5, R48, R50, R74, R97) observed for dining in the sample of 28. The findings include: On June 12, 2023, at 12:35 PM, the pureed meal prep of cooked white rice by V7 (Cook) was observed in the facility kitchen. V7 stated he is preparing pureed meals for 2 residents R50 and R74. After pureeing two 1/2 cup portions of rice with 1/2 cup water in a blender, V7 stated it was ready for service. The rim of the blender around the poring spout still had grains of rice that were not pureed. As R7 tilted the blender to pour the mixture into a pan, some of the whole grains of rice got mixed in with the pureed product. When tested with a spoon, the grains of rice could be felt with the fingers. R7 was notified the pureed mixture was not safe to serve. On June 12, 2023, during lunch meal tray line service, the mechanical soft consistency diets were served white rice along with the meal. The facility…

    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 · E2023-06-20 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 residents the pneumococcal vaccine and administer the influenza vaccine to residents. This applies to 6 of 6 residents (R4, R41, R85, R91, R95, R103) reviewed for immunizations in the sample of 28. The findings include: 1. The EMR (Electronic Medical Record) shows R4 is [AGE] years old and was admitted to the facility on [DATE], with multiple diagnoses including asthma, heart failure, bipolar disorder, and schizophrenia. The facility's documentation titled Authorization and Release for Influenza Vaccine signed by R4 on October 5, 2022, shows R4 consented to receiving the influenza vaccine. The facility does not have documentation to show R4 had received the influenza vaccine during the 2022 to 2023 influenza season. R4's immunization history shows R4 has not received a pneumococcal vaccine. The facility does not have documentation to show R4 was educated about the pneumococcal vaccine and offered the pneumococcal vaccine since R4 was admitted to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-06-20 · 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 a resident's signed POLST (Practitioner Order for Life-Sustaining Treatment) form and physician's order were consistent and reflected the resident's treatment wishes in an event of a medical emergency based on the facility's advance directives guideline. This applies to 1 of 2 residents (R5) reviewed for advance directives in the sample of 28. The findings include: R5 has multiple diagnoses which includes dementia with other behavioral disturbance, type 2 Diabetes mellitus and intellectual disabilities, based on R5's face sheet. R5's admission notification record showed R5 was admitted to hospice care on February 25, 2023, for diagnosis of dementia. R5's quarterly MDS (minimum data set) dated [DATE], shows R5 is severely impaired with cognitive skills for daily decision making and requires total assistance from the staff with most of his ADLs (activities of daily living). R5's order summary report showed an active order dated February 25, 2022,…

    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 · Dcited before2023-06-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy for hand hygiene during resident care. This applies to 1 of 28 residents (R3) reviewed for infection control in the sample of 28. The findings include: On June 14, 2023, at 1:21 PM, V14 (CNA/Certified Nursing Assistant) and V15 (CNA) provided incontinence care to R3. V14 and V15 applied gloves. V14 said R3's incontinence brief was soiled with urine and stool. V14 used a premoistened wipe and wiped R3's front perineal area. V14 and V15 turned R3 onto her side and V14 wiped stool from R3's buttocks. Wearing the same soiled gloves, V14 touched R3's clothes, clean incontinence brief, applied cream to R3's buttocks, and touched R3's thigh when repositioning R3. V14 removed her gloves and applied new gloves. V14 did not perform hand hygiene. V14 then touched R3's leg, clothes, pillow, linens, and bed controls. On June 14, 2023, at 2:17 PM, V2 (DON/Director of Nursing) said facility should change their gloves and perform hand…

    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 · Ecited before2022-07-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who smoke in the facility's ground/patio were supervised all throughout the smoking period. This applies to 6 of 19 residents (R5, R11, R27, R40, R70, R84) reviewed for smoking in the sample of 19. The findings include: On 7/12/12 at 1:50 PM, V4 (Psychiatric Rehabilitation Service Assistant/PRSA) distributed the cigarettes to the residents while V5 (Psychiatric Rehabilitation Service Councilor/PRSC) watched the residents smoking. At 2:05 PM, there were multiple residents (R5, R11, R27, R40, R70, R84) smoking on the patio without staff's presence. V4 and V5 were nowhere in sight. 1. R5's Face Sheet documents that R5 is a [AGE] year-old who has multiple medical diagnoses which include schizophrenia and schizoaffective disorder. R5's Minimum Data Set (MDS) dated [DATE] showed that R5 is alert and oriented. On 7/12/22 at 2:08 PM, R5 was smoking in the facility's patio. On 7/13/22 at 10:44 AM, R5 stated some staff stays…

    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 · Ecited before2022-07-14 · 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 label and date medications after they were opened to determine expiration dates. This applies to 10 of 10 residents (R18, R38, R41, R52, R53, R57, R60, R64, R72, R79) reviewed for labeling and storage of medications. The Findings Include: On [DATE] from 11:00 AM through 11:45 AM, the medication carts and refrigerator (used for medication storage) were inspected with V7 and V17 (Both Nurses). The medication carts and refrigerator were all stored inside the nurses' station. The following medications were observed as follows: 1. R64's Breo Ellipta opened and not dated. 2. R72's Basaglar Kwik Pen and Novolog Insulin were opened and not dated. In addition, R72's Basaglar Kwik pen was opened on [DATE] (expires 28 days after it was opened) and is mixed with the active medications. 3. R52's Insulin Glargine was opened and not dated. 4. R41's two bottles of Latanoprost 0.005% solution eye drops were opened and not dated. 5. R60's Lantus Glargine,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · 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 follow facility's policy and procedure on advance directives. This applies to 1 of 1 residents (R23) reviewed for advance directives in the sample of 19. The findings include: R23's face sheet on EMR (Electronic Medical Records) showed that R23 was (re)admitted on [DATE] with diagnoses of schizoaffective disorder, depressive type, personal history of other venous thrombosis and embolism, chronic embolism and thrombosis of left popliteal vein, hypertension secondary to endocrine disorders, unspecified asthma, uncomplicated, nutritional anemia unspecified. R23's admission MDS (minimum data set) dated [DATE] included that R23 was cognitively intact. On [DATE] at 8:35 AM, the same EMR showed DNR (Do Not Resuscitate) on the dashboard and Physician Order Sheet (revision date [DATE]). R23's POLST/Practitioner Order for Life Sustaining Treatment form effective [DATE] uploaded in EMR showed Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation) and was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to toilet and provide grooming assistance to residents that needed extensive assistance or the same. This applies to 3 of 3 residents (R10, R29, R63) reviewed for Activities of Daily Living care in the sample of 19. The findings include: 1. R29's diagnoses in the EMR (electronic medical records) included schizoaffective disorder, depressive type, other mechanical complication of indwelling ureteral stent, sequela, urinary tract infection, site not specified, abnormal uterine and vaginal bleeding, unspecified, Parkinson's disease. R29's Comprehensive MDS (Minimum Data Set) dated 4/28/2022 included that R29 is cognitively intact and needs extensive one-person physical assist with toilet use and personal hygiene. On 07/11/22 at 1:05 PM, R29 was seated in the dining room and had a strong odor of stale urine. R29 also had multiple long facial/chin hairs (greater than 1/2 inch). On 07/11/22 at 1:09 PM, V7 (Registered Nurse) stated that she is…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-14 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to report high blood pressures of a resident to the Physician in a timely manner. This applies to 1 of 18 residents (R48) reviewed for Nursing Care in the sample of 19. The Findings Include: According to the EMR (Electronic Medical Record) R48 has congestive heart failure and hypertensive heart disease. The same record shows R48 was in the hospital from [DATE] to 6/28/22 and several blood pressure medications were discontinued at that time. On 7/11/22 at 2:30pm, R48 was in a wheelchair. R48 had swollen legs and ankles. R48 stated his ankle did swell every day. R48 stated he had been in the hospital a few weeks earlier and he's ok now. On 7/12/22 the physician's orders for R48 showed he had prescriptions for 2 blood pressure medications and there was an order to measure blood pressure and record it daily in the morning. On 7/12/22 the record of R48's vital signs showed as follows: 6/28/22 at 6:01pm: 171/124 6/30/22 at 11:19am: 139/100 6/30/22…

    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 before2022-07-14 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide pureed entrée portions as shown on the menu spreadsheet during the lunch meal. This applies to 1 of 1 resident (R29) reviewed for pureed diet in the sample of 19. The findings include: On 07/11/22 at 10:27 AM, during initial tour of the kitchen, V13 (Food Service Manager) stated currently the facility only has one resident on pureed diet. On 7/11/22 at 12:53 PM, the lunch meal service was observed in the facility kitchen. V13 stated that the pureed meal for R29 is already plated into bowls which were noted placed in the steam table. Each bowl appeared half full of pureed beef stroganoff, pureed noodles and pureed peas and V13 stated that each of these bowls contains 4 oz/ounce of these items. Facility daily menu spreadsheet for Week 4 Monday showed to use #6 scoop for pureed Beef Stroganoff. On 07/11/22 at 1:03 PM, R29 was seen seated in the dining room and stated I am hypoglycemic, and they don't give me enough food. I eat what they give me. I did not get enough breakfast. They give me a supplement.…

    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 · D2022-07-14 · tag F0888 — isolated
    Ensure staff are vaccinated for COVID-19
    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 were fully vaccinated for COVID-19. This has the potential to affect all 88 residents in the facility. The findings include: On 07/12/22 at 10:55 AM V2 (Director of Nursing/DON) stated not all staff have had COVID-19 boosters. The facility COVID-19 vaccination staff list provided on 07/13/2022 showed they had 54 direct hire staff members. Eight staff members had religious exemptions and five staff members were not fully vaccinated. The facility's vaccination rate was 90.74 percent vaccinated. The following staff members had not received a COVID-19 booster shot: V1 (Administrator). V18 (Licensed Practical Nurse/LPN). V5 (Psychiatric Rehabilitation Services Counselor/PRSC) also tested positive for COVID-19 on 06/10/2022 during a recent COVID-19 outbreak in the facility. V23 (Housekeeping) also tested positive for COVID-19 on 06/13/2022 during a recent COVID-19 outbreak in the facility; and V24 (Dietary) also tested positive COVID-19 on…

    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
  • No harm found · C2023-06-20 · 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 interview and record review, the facility failed to follow their policy for antibiotic stewardship. This has the potential to affect all 105 residents residing in the facility. The Resident Census and Conditions of Resident report dated June 12, 2023, shows the facility census as 105 residents. The findings include: On June 13, 2023, at 1:43 PM, V2 (DON/Director of Nursing) said he is responsible tracking antibiotic use in the facility. V2 continued to say he does not use McGeer's Criteria for collecting infection information because they do not have to in this patient population since there is not a lot of antibiotic use. Review of the facility's Infection Control Log for the period of January 1, 2023, to May 31, 2023, shows 37 antimicrobials were ordered. The facility does not have documentation to show McGeer's Criteria was used to validate the use of the antimicrobial. The facility policy titled Antimicrobial/Antibiotic Stewardship Program dated 4/2020 shows, Guideline: The facility antimicrobial stewardship program includes the following elements; 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.

    Infection Control 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.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in IL

Paying with Medicaid

CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

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 14E212. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-07, 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.

What to do next