Manor Court Of Freeport

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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

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

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

61.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 191 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 46.5% 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 58 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 0.27 therapist hours per resident per day in 2026Q1 — more than 39% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 117 beds and averages 106.9 residents a day — about 91% occupied, or roughly 10 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 3.87 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.76 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.41 hrs/resident/day on weekends vs 4.06 on weekdays — 16% thinner on weekends. RN hours go from 0.82 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% 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

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

Inspection deficiencies

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

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

51 citations, most serious first. The 20 most serious are shown; the remaining 31 are one tap away and print in full.

• Actual harm · Gcited before2026-03-19 · 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 interview and record review, the facility failed to perform weekly skin assessments, failed to identity a pressure ulcer prior to late stages for 1 resident, failed to obtain physician's orders for treatment of a pressure ulcer for 1 resident. This failure resulted in R3 obtaining a Stage 3 pressure ulcer that required surgical debridement and advanced to a Stage 4 pressure ulcer. These failures apply to 1 of 3 residents reviewed for pressure ulcers in the sample of 3.The findings include:R3's electronic face sheet, printed on 3/19/26, showed R3 has diagnoses including but not limited to dementia without behaviors, pain in right hip, stage 3 pressure ulcer to right hip, and depression.R3's facility assessment, dated 12/13/25, showed R3 has moderate cognitive impairment, requires partial/moderate assistance to roll left and right, and is at risk of developing pressure ulcers.R3's care plan, dated 6/10/25, showed, Resident is at increased risk for pressure ulcer related to decreased mobility, generalized muscle weakness, and need for staff assist with transfers .assist…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-08-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safe mobility for residents by not ensuring footrests were on wheelchairs when pushing residents for 4 of 6 residents (R1, R4, R5, & R6) reviewed for safety in the sample of 6. This failure resulted in R1 falling out of the wheelchair and sustaining a laceration that required 3 sutures to close.The findings include:1.R1's Face Sheet, dated 8/19/25, showed diagnoses including vascular dementia, moderate, with psychotic disturbance, encephalopathy, type 2 diabetes mellitus, nutritional anemia, atherosclerotic heart disease, hyperlipidemia, hypokalemia, hypothyroidism, vitamin D deficiency, anxiety disorder, depression, idiopathic gout, pain, overactive bladder, diarrhea, constipation, dysuria, and muscle weakness. The Minimum Data Set (MDS) dated [DATE] for R1 showed moderate cognitive impairment; substantial/maximal assistance needed for toileting, shower/bath, and lower body dressing; partial/moderate assistance needed for upper…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-08 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 administer a resident's (R1) sodium tablets for 12 days following his admission to the facility. This failure resulted in R1 experiencing a critically low sodium level, confusion, hallucinations, and a 15 day hospital stay to correct his sodium levels. This applies to 1 of 3 residents reviewed for medications in the sample of 5. The findings include: R1's electronic face sheet printed on 7/8/25 showed R1 has diagnoses including but not limited to permanent atrial fibrillation, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), chronic kidney disease, and malignant neoplasm of bladder. R1's census report showed R1 was admitted to the facility on [DATE], and discharged to a local hospital on 6/16/25. R1 did not return to the facility. R1's local hospital discharge orders, dated 6/5/25, showed, NEW: Sodium Chloride 1gm PO (oral) QID (4 times per day) .Discontinued: sodium chloride 1,000mg PO TID (3 times per day) . R1's physician's…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-09 · 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 ensure a safe transfer by not using a gait belt for one resident, (R3), and failed to ensure one resident (R1) was safely transferred. This failure resulted in R1 falling during a staff assisted transfer and sustaining multiple lacerations to her head requiring sutures. This applies to 2 of 3 residents (R1 and R3) reviewed for safety in the sample of 3. The findings include: 1. R1's Care Plan shows, Transfer Program: 1. Set up devices for transfer. 2. Encourage [R1] to stand using chair arms or edge of bed to push off from and come to a standing position. 3. Encourage [R1] to turn using walker until back of body is in front of source to transfer to. 4. Encourage [R1] to reach back and place hands on chair arms or edge of bed prior to sitting. 5. Encourage [R1] to sit down slowly. R1's Emergency Department Note, dated 1/3/25, shows, Pt (Patient) states she fell while getting out of bed. Pt has laceration to forehead Patient hit her face on the ground. She presents with a laceration type injury to her left…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was wearing non-skid footwear and was being held by the gait belt when being transferred/ambulated for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3 residents. This failure resulted in R1 falling and sustaining a rib fracture, two transverse process fractures of the lumbar vertebrae, and a skin tear. The findings include: R1's Face Sheet, dated 11/25/24, shows R1 was admitted to the facility on [DATE]. R1's diagnoses include, but are not limited to, fracture of neck of right femur (hip), presence of right artificial hip joint, Parkinson's disease, muscle weakness, unsteadiness on feet, pain, and an unspecified fall. R1's Fall Risk, dated 10/2/24, shows R1 was a high fall risk. R1's Care Plan (problem start date 10/3/24) shows R1 is at risk for falling. The facility's Event Report, completed 11/20/24 at 3:26 PM, shows R1 had a fall on 11/19/24 at 9:42 PM in his room. The report shows R1 feels he fell…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to immediately notify a physician of a fall with new onset of pain, failed to monitor and assess a resident post fall for pain and change of condition, and failed to provide pain medication for a resident experiencing pain after a fall for 1 of 3 residents (R1) reviewed for quality of care. This failure resulted in R1 not being transferred to the acute care hospital for evaluation for 19 hours after a fall with a fractures. The findings include: R1's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include congestive heart failure, dysphagia, Chronic Obstructive Pulmonary disease, Malignant neoplasm of prostate, Alzheimer's Disease with late onset, muscle weakness, venous insufficiency, chronic kidney disease, atherosclerotic heart disease of native coronary artery, unsteadiness on feet, anxiety disorder, repeated falls, and abnormality of gait and mobility. R1's facility assessment, dated 7/2/24, showed he 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform a safe transfer for 1 of 3 residents (R1) reviewed for safety in the sample of 5. This failure resulted in R1 experiencing a fall and fracturing his left arm and shoulder. The findings include: R1's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include congestive heart failure, dysphagia, Chronic Obstructive Pulmonary disease, Malignant neoplasm of prostate, Alzheimer's Disease with late onset, muscle weakness, venous insufficiency, chronic kidney disease, atherosclerotic heart disease of native coronary artery, unsteadiness on feet, anxiety disorder, repeated falls, and abnormality of gait and mobility. R1's facility assessment, dated 7/2/24, showed he has severe cognitive impairment and requires substantial/maximal staff assistance for transfers. (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) On 9/10/24 at 1:17 PM, R1 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-29 · 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 identify a pressure wound prior to becoming advanced stages, failed to identify deterioration of an existing pressure ulcer, failed to perform weekly wound assessments, failed to perform accurate wound assessments for 2 residents (R75, R63), failed to provide wound treatments, failed to maintain documentation of wound assessments for 1 resident (R16), and failed to ensure pressure ulcer prevention measures were in place for 1 resident (R63). These failures resulted in R75 experiencing sepsis requiring hospitalization, surgical debridement of his necrotic wound, and placement of a colostomy due to an infected wound. These failures also resulted in R63's bilateral heel wounds not being identified until they were unstageable wounds and becoming necrotic. These failures apply to 3 of 6 (R75, R63, R16) residents reviewed for pressure ulcers in the sample of 23. The findings include: 1. R75's electronic face sheet, printed on 8/29/24, showed R75 has diagnoses including but not limited to pressure ulcer stage 4,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-08-29 · 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 implement interventions for residents with significant weight loss for 3 of 4 residents (R82, R70, R83) reviewed for weight loss in the sample of 24. These failures caused R82 to experience a 9.91% weight loss in 1 month, R70 to experience a 10.40% weight loss in 1 month, and R83 to experience a 12.18% weight loss in 1 month and a 18.55% weight loss in 3 months. The findings include: 1. R82's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include chronic atrial fibrillation, congestive heart failure, pressure ulcer of sacral region, anxiety disorder, anemia in chronic kidney disease, and obstructive and reflux uropathy. On 8/28/24 at 9:12 AM, R82 said he has lost weight since he has been at the facility. R82 said he thinks maybe they may want him to lose weight. R82 said he is not on any nutritional supplements. R82's record showed on 7/11/2024, he weighed 212 lbs. (pounds) and on 8/08/2024, the resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-09 · 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 ensure a resident (R1) who is a high risk for falls was provided with the appropriate shower device during a shower. The failure resulted in R1 sustaining a fracture to his right hip. This applies to one of three residents, (R1) reviewed for showers in a sample of three. The findings include: R1's face sheet, printed on 1/5/24, showed diagnoses to include but not limited to systolic/diastolic congestive heart failure, anemia, respiratory failure, atrial fibrillation, chronic kidney disease stage 5, difficulty walking, and generalized muscle weakness. R1's MDS (Minimum Data Set), dated 1/2/24, showed R1 has no cognitive impairment. R1 requires partial to moderate assist with shower transfers and showers. R1 has had one major fall with an injury. R1's care plan dated, 12/5/23-1/5/24, showed R1 is at risk for falls related to recent illness, hospitalization and new environment. R1's quarterly fall risk assessment, dated 12/6/23, showed R1 as high risk for falls. R1's fall event, printed on 1/5/24, showed R1 had…

  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 · D2026-06-30 · 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

  Based on interview and record review, the facility failed to ensure accuracy of medical records for 1 of 3 residents (R1) reviewed for medical records in the sample of 3.The findings include:On 6/30/26 at 9:22 AM, R1 was on the locked memory care unit. R1 could not recall the events of her fall on 6/20/26 or even that she had fallen. R1's facility Fall Investigation for 6/20/26 indicated R1 was unable to be interviewed. R1's progress note, dated 6/20/26 at 2:28 PM, showed R1 was in her room walking to the bathroom with V8 (Certified Nursing Assistant- CNA), tripped backwards, and landed on her buttock. The progress note indicated staff were present and the fall was witnessed. On 6/30/26 at 10:11 AM, V8 said he was providing care to R1's roommate in the bathroom with the bathroom door closed when he heard R1 yell. V8 said he opened the bathroom door and saw R1 had fallen next to her bed. V8 said he was not walking with R1 when she fell and did not witness R1 fall. V8 said when he opened the bathroom door there were no other staff present to witness the fall. V8's interview indicated…

  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 · E2026-04-23 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  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 there were staff available to administer resident medications according to schedule administration times for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for staffing in the sample of 5.The findings include: On 4/23/26 at 8:50 AM, V4, Licensed Practical Nurse (LPN), said she had worked this past weekend (4/18/26-4/19/26). V4 said on Saturday, 4/18/26, one of the 3 scheduled nurses for day shift called off, so they were short. V4 said at 10:00 AM, she found out an entire hallway still had not received their morning medications. V4 said R1 and R2 (who live down that hallway) were very upset. V4 said when there are 3 scheduled nurses, 2 of the nurses split the memory care unit so there isn't a nurse in that unit all the time. 1.On 4/23/26 at 11:05 AM, R1 was in his wheelchair sitting at the dining room table. R1 said on Saturday, they were short nurses, and he didn't get his sugar checked or his morning medications until almost 10:45 AM. V4 said he is supposed to get his morning medications (including…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-04-23 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to administer resident medications according to Physician Orders for 4 of 5 residents (R1, R2, R3, R5) reviewed for medications in the sample of 5.The findings include: On 4/23/26 at 8:50 AM, V4, Licensed Practical Nurse, said she had worked this past weekend (4/18/26-4/19/26). V4 said on Saturday, 4/18/26, one of the 3 scheduled nurses for day shift called off, so they were short. V4 said at 10:00 AM, she found out an entire hallway still had not received their morning medications. V4 said R1 and R2 were very upset.1.On 4/23/26 at 11:05 AM, R1 was sitting in his wheelchair in the dining room. R1 said on Saturday they were short nurses, and he didn't get his sugar checked or his morning medications until almost 10:45 AM. V4 said he is supposed to get his morning medications (including insulin) before breakfast at 7:30 AM. R1's Medication Administration Record (MAR) shows on 4/18/26, R1 received Depakote at 10:27 AM (scheduled time 7:00 AM), furosemide 10:27 AM (scheduled time 6:00 AM-10:00 AM), gabapentin at…

  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 before2026-04-23 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  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 residents were free of significant errors for 4 of 5 residents (R1, R2, R3, R5) reviewed for medications in the sample of 5.The findings include: On 4/23/26 at 8:50 AM, V4 Licensed Practical Nurse said she had worked this past weekend (4/18/26-4/19/26). V4 said on Saturday 4/18/26 one of the 3 scheduled nurses for day shift called off, so they were short. V4 said the night nurses had to stay to help pass medications. V4 said she said she got busy doing her assigned hallways and was not sure what the night nurses were doing. V4 said at 10:00 AM, she found out an entire hallway still had not received their morning medications. V4 said R1 and R2 were very upset.1.On 4/23/26 at 11:05 AM, R1 was sitting in his wheelchair in the dining room. R1 said on Saturday they were short nurses, and he didn't get his sugar checked or his morning medications until almost 10:45 AM. V4 said he is supposed to get his morning medications (including insulin) before breakfast at 7:30 AM. R1's Medication Administration Record…

  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 · D2026-03-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to protect a resident from abuse. This applies to one of three residents (R2) reviewed for abuse in the sample of three.The findings include:A facility reported incident, dated 3/19/26, shows R2 was found at around 5:30AM on 3/11/26, in her bed, with R1 standing over her placing a pillow over R2's head area. R1 was removed from the room by the two Certified Nursing Assistants (CNA). R2 did not seem in any distress.The facility face sheet for R2 shows she was admitted to the facility with a diagnosis of dementia. The facility assessment for R2, dated 2/17/26, shows her to have severe cognitive impairment and required supervision with her mobility. A progress note, dated 3/11/26, shows communication with R2's Power of Attorney (POA) that R2 had been awakened by her roommate who had held a pillow to her face.The facility face sheet for R1 shows she was admitted to the facility with a diagnosis of Alzheimer's Disease. The facility assessment, dated 3/12/26, shows her to have severe cognitive impairment and requires supervision…

  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 · D2026-03-26 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to report an allegation of physical abuse of a resident in a timely manner. This applies to one of three residents (R2) reviewed for abuse in the sample of three.The findings include:A facility reported incident, dated 3/19/26, shows R2 was found at around 5:30AM on 3/11/26, in her bed, with R1 standing over her placing a pillow over R2's head area. R1 was removed from the room by the two Certified Nursing Assistants (CNAs). R2 did not seem in any distress.The facility face sheet for R2 shows she was admitted to the facility with a diagnosis of dementia. The facility assessment for R2, dated 2/17/26, shows her to have severe cognitive impairment and required supervision with her mobility. A progress note, dated 3/11/26, shows communication with R2's Power of Attorney (POA) that R2 had been awakened by her roommate who had held a pillow to her face.The facility face sheet for R1 shows she was admitted to the facility with a diagnosis of Alzheimer's Disease. The facility assessment, dated 3/12/26, shows her to have severe…

  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 · D2026-03-19 · 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 honor a residents (R1) Advanced Directive, resulting in (R1) being resuscitated against her wishes. This failure applies to 1 of 3 residents reviewed for Advanced Directives in the sample of 3.The findings include:R1's electronic face sheet, printed on [DATE], showed R1 had diagnoses of COVID-19, rib contusion, chronic kidney disease, depression, and venous insufficiency.R1's physician's orders, dated [DATE], showed, Do Not Resuscitate (DNR).R1's banner on her electronic medical record, created [DATE], showed, Full Code.R1's Physician's Orders for Life Sustaining Treatment (POLST) form, dated [DATE], showed, No CPR (Cardiopulmonary Resuscitation): Do not attempt Resuscitation. R1's POLST form was not scanned into her electronic medical record until [DATE].R1's nursing progress notes, dated [DATE], showed, This nurse called to residents' room regarding a fall. Went to resident's room and she was on the floor facing down, her arms tucked in and she 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 before2026-03-19 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a resident (R2) was free from significant medication errors. This applies to 1 of 3 residents reviewed for medications in the sample of 3.The findings include:R2's electronic face sheet, printed on 3/19/26, showed R1 has diagnoses including but not limited to Parkinson's Disease, pressure ulcer of sacral region stage 4, Alzheimer's disease, and dementia without behaviors.R2's care plan, dated 3/10/26, showed, (R2) has a wound infection. Antibiotic therapy to be completed 4/22/26.R2's CT (Computed Tomography) scan, dated 3/4/26, showed, Correlate for cellulitis and sinus track at the natal cleft with induration extending centrally to the coccygeal segments with significant posterior bone loss and erosions in the mid and lower coccygeal segments. Osteomyelitis has similar appearance. Correlate for surgical debridement .R2's wound physician note, dated 3/9/26, showed, Investigations recommended and/or reviewed: CT scan of Stage 4 pressure wound sacrum demonstrates osteomyelitis. Similar finding on 3/4/26…

  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 · F2025-11-25 · 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 proper cooling techniques were utilized, failed to maintain cleanliness of unit food storage areas, and failed to maintain facility freezer in proper working condition. These failures have the potential to affect all residents in the building. The facility roster, dated 11/23/25, showed 110 residents residing in the facility.On 11/23/25 at 11:00AM, the initial tour of the kitchen was conducted. The thermometer reading on the facility's walk-in cooler registered at 0 degrees Fahrenheit. V25 (Cook) stated the temperature should be higher than that. A container of Salisbury steak inside the cooler appeared frozen. A previously cooked pork roast was loosely covered in a pan with aluminum foil and showed a use by date of 11/27/25. V25 stated the roast was cooked on Thursday (11/20/25). The facility's walk-in freezer had a thick layer of ice from water that dripped on food items on the top shelf and on top of ice cream cups and popsicles. Additionally, a layer of thick frost/ice was on the top left shelf 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-25 · 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 a resident with dysphagia received thickened liquids and was supervised when eating to prevent her from eating another resident's food and large amount of food at once for 1 of 1 resident (R33), and the facility failed to ensure the hot water and coffee in 3 of 4 dining rooms were at safe temperatures, for residents reviewed for safety and supervision in the sample of 50. This failure has the potential to affect residents in 3 of 4 dining areas.The findings include: 1. On 11/23/25 at 12:32 PM, R33 was sitting in her wheelchair at a dining room table, with three other residents and a resident's wife for the noon meal. R33 was sitting next to R22, who had a grilled cheese that was quartered. R33 had taken a quarter of R22's grilled cheese sandwich, used it like a spoon, put meat on top of it, and then shoved it in her mouth. There were no staff at the table at this time. V19 (R115's wife) was at the table and alerted staff R33…

  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.

Fines & penalties

$124,331 in federal fines across 6 penalties.

• $48,620 — penalty dated 2026-03-19
• $11,196 — penalty dated 2025-08-19
• $13,161 — penalty dated 2025-07-08
• $14,505 — penalty dated 2025-01-09
• $14,050 — penalty dated 2024-11-25
• $22,799 — penalty dated 2024-08-29

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 RESIDENTIAL ALTERNATIVES OF ILLINOIS — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $163K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). 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