Stephenson Nursing Center
2946 South Walnut Road, Freeport, IL 61032 · Government - County · 148 certified beds · (815) 235-6173 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Feb 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 4 actual-harm citations
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (40) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $18,450 in federal fines (most recent 2026-02-26)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 fell from 3 to 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.3% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.0% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 13.7% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.2% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.6% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.2% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.9% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.0% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 86.7% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 24.5% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.1% | 13.9% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.4%CMS range 6.3–15.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.05 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 148 beds and averages 70.8 residents a day — about 48% occupied, or roughly 77 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.06 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.74 hrs/resident/day on weekends vs 3.19 on weekdays — 14% thinner on weekends. RN hours go from 0.99 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
40 citations, most serious first. The 15 most serious are shown; the remaining 25 are one tap away and print in full.
- Actual harm · Gcited before2026-03-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interview and record review the facility failed to supervise a resident at risk for falls. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 6. This failure resulted in R1 sustaining a left hip fracture. This past compliance occurred from 2/22/26 to 2/23/26. Past noncompliance-no plan of correction required. The findings include:R1's admission Record (Face Sheet) showed an Original admission date of 11/18/25 with diagnoses to include but not limited to Alzheimer's dementia, unsteadiness of feet, weakness, and rheumatoid arthritis. R1's 2/28/26 Minimum Data Set (MDS) showed she was unable to complete the Brief Interview for Mental Status test, and she has both short and long-term memory problems. R1's 2/10/26 Restorative Note from 9:08 AM showed, On 2/5 (2/5/26) staff in (locked memory care) unit informed me that occasionally when [R1] is tired or not walking well in general she tends to walk too far behind her rollator (walker). I observed her ambulating (walking) with it and did not notice any concerns at that time. I called her husband. to discuss…
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.
- Actual harm · Gcited before2026-02-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 safe mechanical lift transfer for a resident (R11) dependent upon staff for transfers. This failure resulted in R11 sustaining a right fracture. The facility also failed to ensure a stable chair was provided for a resident (R16) to prevent falls. These failures apply to 2 of 5 residents reviewed for safety and supervision in the sample of 38. The findings include:1. R11's face sheet showed she was admitted to the facility 11/27/2017 with diagnoses to include spastic hemiplegic cerebral palsy, major depressive disorder, hypertension, and primary generalized osteoarthritis. R11's facility assessment dated [DATE] showed she has moderate cognitive impairment and is dependent upon staff for transfers. R11's care plan initiated 1/27/26 showed, Resident wears sling to right arm due to right arm injury. Will wear sling to improve pain. R11's care plan initiated 11/28/2017 showed, Resident is at risk for falls. Approaches. Date Initiated:…
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.
- Actual harm · G2025-06-04 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 discharge services were in place prior to discharging a resident to independent senior housing who requires assistance with activities of daily living. This failure resulted in R1 being found in her apartment soiled in urine and feces and unable to get out of bed. This applies to 1 of 3 (R1) residents reviewed for discharge in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnosis including osteoarthritis left hip, abnormalities of gait and mobility, type 2 diabetes unspecified dementia and cognitive communication deficit. R1's face sheet shows she was admitted to the facility on [DATE] and discharged on 5/30/25. R1's care plan initiated March 17, 2025 shows R1 has difficulty understanding others, hard of hearing, cognitive and memory deficits. R1 is a fall risk and requires staff assistance with ambulation, has urinary incontinence and requires staff to provide incontinence care. R1's current…
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.
- Actual harm · Gcited before2025-05-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 staff applied a gait belt for a resident who is high risk for falls. This failure resulted in R1 falling on the floor while ambulating without a gait belt and sustained a left femur fracture requiring surgical repair. This applies to 1 of 3 (R1) residents reviewed for falls in the sample of 3. The findings include: R1's Final Serious Injury Incident Report dated 5/8/25 shows R1 is an [AGE] year-old female, alert and oriented x3. On 5/5/25 at 10:00 PM, (R1) sustained a fall while exiting the bathroom. V5 (Certified Nursing Assistant-CNA) was assisting (R1) back to the recliner after toileting. (R1) became weak and began to fall .(R1) complained of leg pain and was assessed by the nurse and sent out to the local hospital. R1 sustained a left femur fracture requiring surgical repair. R1's Fall Risk assessment dated [DATE] shows she is high risk for falls. R1 has balance problems while standing and walking, requires the use of assistive…
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.
- Actual harm · G2025-02-04 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 residents' pain regimen was adequate to relieve her pain for one of 13 residents (R14) reviewed for pain in the sample of 13. This failure resulted in R14 experiencing unrelieved pain for three days. The findings include: R14's Physician Order Report dated January 3, 2025-February 3, 2025 shows she was admitted to the facility on [DATE] with diagnoses including nonrheumatic aortic valve stenosis, acute diastolic congestive heart failure, depression, gastrointestinal stromal tumor of stomach, age related osteoporosis, scoliosis thoracic region, muscle weakness, and abnormalities of gait and mobility. R14's medications orders show an order for ibuprofen 200 mg two tablets every four hours as needed to start on December 6, 2024, an order for ibuprofen 200 mg three tablets twice a day for pain to start on December 10, 2024, and morphine liquid 10 mg every two hours as needed to start January 30, 2025. R14's Care Plan created December…
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.
- Potential for harm · Fcited before2026-02-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 dietary staff covered their facial hair while preparing food for the residents, and while cleaning dishes. The facility failed to ensure staff used chemical sanitation to disinfect a food preparation table and equipment; failed to ensure staff were knowledgeable about the concentration level that was needed when testing the chemical sanitation; and failed to ensure cold desserts were maintained below 41 degrees Fahrenheit. This failure has the potential to affect all the residents in the facility.The findings include:The CMS 671 form completed by the facility on 2/24/26 showed 70 residents resided in the facility on 2/24/26.The document provided by the facility on 2/26/26, showed the only resident residing in the facility that does not receive nutrition by mouth is R21.On 2/24/26 at 9:17 AM, In the dish washing area of the facility, V17 (Dietary Cook) was doing the breakfast dishes. No gloves and no hair net covering his beard. V17 went across to the kitchen area to the hand washing station, to wash…
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.
- Potential for harm · D2026-02-26 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 resident dignity was maintained during personal care for 2 of 2 residents (R13, R48) reviewed for dignity in the sample of 38. The findings include:1. R13's face sheet printed on 2/26/26 showed diagnoses including but not limited to traumatic subdural hemorrhage, speech and language deficits, autistic disorder, and left side paralysis. R13's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed total staff assistance required for bathing, dressing, personal hygiene, and transfers. On 2/25/26 at 9:10 AM, V6 (CNA-Certified Nurse Aide) performed morning hygiene care for R13. V6 removed R13's clothing and did a bed bath. R13's face, chest, groin area, and buttocks were washed during the process. R13 was rolled repeatedly from side to side during the process. The window curtain was not closed and R13 was visible to the neighboring wing windows. R13 was dressed and transferred to the wheelchair.…
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.
- Potential for harm · D2026-02-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for a resident with a diagnosis of post-traumatic stress disorder (PTSD) for 1 of 1 resident (R79) reviewed for PTSD in the sample of 38.The findings include:R79's admission Record, provided by the facility on 2/26/26, showed she had diagnoses including post-traumatic stress disorder, unspecified, bipolar disorder, in partial remission, major depressive disorder, and generalized anxiety disorder. All of these diagnoses had an onset date of 12/29/23. R79's facility assessment dated [DATE] showed she has moderate cognitive impairment and partial to moderate assistance from staff for dressing, bathing, and toilet hygiene. The assessment showed R79 is independent with bed mobility and transfers.On 02/24/2026 at 12:51 PM, R79 was alert, oriented. Cognitively intact. Well-groomed. R79 was smiling and pleasant. No signs of withdrawal, anger, depression. R79 interacted with staff and other residents. R79 said she likes it 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.
- Potential for harm · Dcited before2026-02-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for 1 of 5 residents (R26) reviewed for pressure ulcers in the sample of 38. The findings include: R26's face sheet printed on 2/26/26 showed diagnoses including but not limited to paralysis of upper limb following cerebral infarction affecting right dominate side, right hip/buttock stage 3 pressure ulcer, right and left knee stiffness, and muscle weakness. R26's facility assessment dated [DATE] showed partial to moderate staff assistance required for bed rolling. The assessment showed total staff assistance required for putting on footwear. The same assessment showed R26 had no cognitive impairment. R26's pressure ulcer risk assessment dated [DATE] showed risk for pressure ulcer development. R26's most recent weight dated 2/12/26 showed 193.4 pounds. On 2/24/26 at 2:25 PM, R26 was seated in a wheelchair in his room. R26 wore black socks and both feet were resting directly on the floor.…
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.
- Potential for harm · Dcited before2026-02-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure catheter tubing was positioned in a manner to prevent it from dragging across the floor as a resident was propelling his wheelchair for 1 of 1 resident (R46) reviewed for catheters in the sample of 38.The findings include:R46's admission Record provided by the facility on 2/26/26, showed he had diagnoses including, but not limited to chronic kidney disease, stage 3A, disorder of prostate, unspecified, urine retention, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy (urine flow is blocked or flows backward into the kidneys), vesicoureteral-reflux with bilateral reflux nephropathy with hydroureter (the backward flow of the urine from the bladder to the kidneys leads to scarring, infection, and potential chronic failure). R46's facility assessment dated [DATE] showed he had moderate cognitive impairment, Requires supervision or touch assistance for toileting, bathing, bed mobility and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-26 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary 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 ensure a gradual dosage reduction was attempted for a resident prescribed multiple psychotropic medications. This applies to 1 of 5 residents (R16) reviewed for unnecessary medications in the sample of 38.The findings include:R16's face sheet showed she was admitted to the facility 6/24/25 with diagnoses to include encephalopathy, lack of coordination, hypothyroidism, Type 2 Diabetes, dementia with other behavioral disturbance, bipolar disorder, major depressive disorder, obstructive sleep apnea, chronic pain, muscle weakness, disorders of muscle, fibromyalgia, unsteadiness on feet, and abnormalities of gait and mobility. R16's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires supervision and touch assistance for most cares. This same assessment showed R16 exhibited no behaviors. On 2/24/26 at 12:00 PM, R16 was in the common area during the lunch meal. On 2/25/26 at 9:30 AM, R16 was in the common…
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.
- Potential for harm · Dcited before2026-02-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff wore the required personal protective equipment when providing high-contact resident care activities for 1 of 7 residents (R9) reviewed for infection control in the sample of 38.The findings include:R9's admission Record, provided by the facility on 2/26/26, showed diagnoses of moderate protein-calorie malnutrition, muscle weakness, paraplegia, cachexia (a complex, progressive syndrome characterized by severe weight loss, muscle atrophy, and fat depletion), ataxia (a lack of muscle coordination affecting gait, speech, eye movements, and swallowing), degenerative disease of nervous system, neuropathy, stage 4 pressure ulcers on his buttocks sacrum, left and right lower back, and an unstageable pressure ulcer right heel. All the pressure ulcers were present on admission. The admission Record showed R9 had a colostomy on admission, and a gastrostomy tube was initiated on 12/26/25. R9's 1/31/26 facility assessment showed he is cognitively intact, is dependent on staff for all activities of daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-03 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to apply a narcotic pain patch in an inaccessible location for a resident with a history of removing narcotic pain patches. This applies to 1 of 3 residents reviewed for medications in the sample of 5. The findings include: R1's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses including scoliosis and dementia. R1's 1/23/25 Minimum Data Set (MDS) showed the resident was not able to complete the Brief Interview for Mental Status and she had both short and long-term memory problems. R1's MDS showed she was dependent upon staff for functional abilities except eating which she required substantial/maximal assistance. R1's MDS showed she had frequent pain. The facility's 3/1/25 incident report submitted to the state health department showed R1's fentanyl (schedule II narcotic pain medication) patch, which was on her body, had gone missing. The report showed a replacement patch was applied. R1's fentanyl order history showed she 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.
- Potential for harm · Fcited before2025-02-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 maintain their kitchen in a clean and sanitary manner. The facility failed to ensure staff handled kitchen utensils in a manner to prevent cross contamination. These failures have the potential to affect all 46 residents in the facility. The findings include: The facility's Long-Term Application for Medicare and Medicaid form dated 2/2/25 showed a resident census of 46. On 2/2/25 at 9:26 AM, an initial tour of the facility's kitchen was conducted. During the tour, the following observations were noted: 1. Dried grease and food debris noted across the top of the stove, down the front of the ovens, and down the sides of the steamers. 2. Four, individual plastic quart containers, each containing dried cereal, were noted on one of the kitchen counters. Each lid, on the containers, appeared dirty and were sticky to the touch. A brown, sticky substance was noted on the side of one of the containers. 3. A plastic milk crate, noted on the bottom shelf of a rack next to the stove, was covered with grease and sticky…
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.
- Potential for harm · F2025-02-04 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to ensure certified nursing assistants (CNA) working in the facility received their annual abuse and dementia care training/education. This failure has the potential to affect all 46 residents in the facility. The findings include: The facility's Long-Term Application for Medicare and Medicaid form dated 2/2/25 showed a resident census of 46. The facility's nursing schedule showed the following agency CNA's provided cares to residents in the facility: V7 CNA on 2/2/25 V8 CNA on 1/20/25-1/24/25 V9 CNA on 1/20/25, 1/23/25-1/31/25 On 2/4/25 at 7:39 AM, V2 Director of Nursing stated V7-V9 CNA's had not completed any abuse or dementia trainings in the last year. V2 stated V7-V9 are agency CNA's. I called their agency. They said (V7-V9 CNA's) had not received the trainings. They didn't attend our abuse or dementia trainings here. The facility's assessment (originally dated 8/18/2017; revised 2025) showed, We accept residents with the following diagnosis, diseases, and condition . Alzheimer's disease, dementia . Human Resources and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 25 citations
- Potential for harm · E2025-02-04 · tag F0604 — failed to not use physical restraints improperly — patternEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents were not restrained from being able to exit their beds for 4 of 13 residents (R5, R11, R19 and R35) reviewed for restraints in the sample of 13. The findings include: 1. On 2/2/25 10:26 AM, R11 was lying in bed. R11 had siderails on the upper half of her bed in a raised position on both sides of her bed. R11 had bolsters (wedge shaped cushions) attached to each side of her bed measuring 33 inches long and 7 inches high. The bolsters were attached to the bed with two straps holding them in place. There was 23 inches from the end of the bolster to the end of her bed. On 2/4/25 at 9:40 AM, R11 was lying in bed and the siderails and bolsters were in the same position. On 2/4/25 at 9:40 AM, V15 (Certified Nursing Assistant) said R11 has the bolster in place so she does not get out of bed. V15 said R11 is not able to independently use her side rails for positioning herself. R11's Fall Care Plan dated 11/26/24 shows, [R11] is 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.
- Potential for harm · D2025-02-04 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure misappropriation of residents' property did not occur for two of four residents (R41, R11) reviewed for misappropriation in the sample of 13. The findings include: 1. R41's Physician Order Report dated January 3, 2025-February 3, 2025 shows he was admitted to the facility on [DATE] with diagnoses including heart disease, dementia with agitation, dehydration, anxiety disorder, and urinary tract infection. There is an order for hydrocodone-acetaminophen (Norco) 5-325 one tablet for pain every four hours as needed. The facility's Preliminary Incident Investigation Report dated February 1, 2025 shows, January 31, 2025, during the shift to shift narcotic count it was noted that five Norco 5-325 tablets were missing from the bottle. Name of resident allegedly abused or neglected: [R41]. R41's Norco 5-325 Controlled Substance Record shows R41's bottle of Norco was not counted on the night shift of January 30, 2025. On January 31, 2025 at 3:00 AM, there…
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.
- Potential for harm · D2025-02-04 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 their abuse policy was implemented for one of four residents (R11) reviewed for abuse policy and procedures in the sample of four. The findings include: R11's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and encounter for palliative care. R11's Physician Order Report dated December 1, 2024-December 31, 2024 shows an order for fentanyl patch 25 mcg every 72 hours. R11's Progress Note dated December 21, 2024 done by V24 RN (Registered Nurse) shows, Resident is due to have new fentanyl patch administered per order. This writer unable to locate current patch on left chest as indicated in electronic medical record. New patch applied early to right back related to no current transdermal pain relief present on resident body. An attempt was made to talk to V24 via phone on February 4, 2025. A message was left with no call back. 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.
- Potential for harm · Dcited before2025-02-04 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report a missing controlled substance for one of four residents (R11) reviewed for reporting abuse in the sample of four. The findings include: R11's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and encounter for palliative care. R11's Physician Order Report dated December 1, 2024-December 31, 2024 shows an order for fentanyl patch 25 mcg every 72 hours. R11's Progress Note dated December 21, 2024 done by V24 RN (Registered Nurse) shows, Resident is due to have new fentanyl patch administered per order. This writer unable to locate current patch on left chest as indicated in electronic medical record. New patch applied early to right back related to no current transdermal pain relief present on resident body. An attempt was made to talk to V24 via phone on February 4, 2025. A message was left with no call back. On February 4, 2025…
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.
- Potential for harm · D2025-02-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
Based on observation, interview and record review the facility failed to ensure a resident who is dependent on staff for Activities of Daily Living (ADLs) was provided incontinence care in a timely manner for 1 of 13 residents (R5) reviewed for ADLs in the sample of 13. The findings include: On 2/3/25 at 8:13 AM, R5 was in the dining room eating breakfast. At 10:34 AM, V11 (Certified Nursing Assistant) and V12 (Registered Nurse) transferred R5 into bed using a mechanical lift. R5's mechanical lift sling was removed from under him and then his blankets were pulled up. V11 and V12 then exited the room. V11 or V12 did not check to see if R5's incontinence brief needed to be changed. At 11:29 AM, V11 provided incontinence care to R5. R5's incontinence brief was saturated. R5's green sweatpants had visible wet spots on the back of them. R5's front perineal area was reddened. R5 had a small amount of stool present. R5's buttocks was reddened. On 2/3/25 at 2:48 PM, V2 (Director of Nursing) said residents should be checked for incontinence every 2 hours and as needed. V2 said if staff are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure protective arm sleeves were applied to a resident with fragile skin and a history of skin tears for 1 of 13 residents (R11) reviewed for quality of care in the sample of 13. The findings include: R11's Nursing Notes dated 12/13/24 shows, Resident bumped arm on table at breakfast and sustained a skin tear of 2.5 cm by 0.5 cm to (R) outer forearm . R11's Nursing Notes dated 1/29/25 shows, Resident bumped her right FA (forearm) on the table at lunch and sustained a 1.5 cm (centimeter) x 0.5 cm skin tear On 2/2/25 at 10:26 AM, V15 (Certified Nursing Assistant) and V16 (Registered Nurse) provided incontinence care to R11 and got her up into her high back wheelchair. R11 had arm protector sleeves on her bedside table. R11 had a short sleeved shirt on. R11 had a dressing to her right forearm. V16 stated that it was a skin tear from bumping her arm on the dining room table. At 12:11 PM, R11 was sitting at the dining room table. R11 did not have protective arm sleeves on. R11 did not have long sleeves on. 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.
- Potential for harm · Dcited before2025-02-04 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility to ensure pressure ulcer prevention interventions were implemented for a resident at risk for pressure ulcers and failed to ensure dietary recommendations were implemented for a resident with a stage 3 pressure ulcer. This applies to 2 of 4 residents (R5 and R11) reviewed for pressure ulcers in the sample of 13. The findings include: 1. On 2/2/25 at 2:52 PM, V10, Certified Nursing Assistant (CNA) was in R5's room assisting R5's roommate. R5 was lying in bed. R5's air mattress was not plugged into the wall. When the mattress was pressed on slightly, the metal bed frame was able to be felt. At 3:00 PM, V10 exited the room. R5's air mattress was still unplugged. On 2/2/25 at 2:52 PM, V15 (CNA) said R5 was placed back into bed around 1:00 PM. On 2/2/25 at 3:49 PM, V4 (Wound Care Registered Nurse) said R5 has an air mattress due to him being at high risk for pressure ulcers. V4 went into the room and plugged R5's air mattress into the wall. R5's air…
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.
- Potential for harm · Dcited before2025-02-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident did not wear a urinary drainage leg bag while in bed for one of two residents (R35) reviewed for catheters in the sample of 32. The findings include: R35's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including congestive heart failure, altered mental status, chronic kidney disease, urinary retention, and obstructive and reflux uropathy. R35's Care Plan started September 7, 2024 shows, [R35] requires an indwelling urinary catheter. History of retention and urinary tract infections. On February 2, 2025 at 9:35 AM, R35 was lying in bed. R35 had his knees bent up and he was laying on his back. There was no urinary drainage bag visible on either side of R35's bed. At 9:40 AM, V7 CNA (Certified Nursing Assistant) said R35 has a catheter (urinary drainage device). V7 said R35 has a leg bag on while he's in bed. At 9:42 AM, there was a sing about R35's bed that showed, Do not leave leg bag on when…
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.
- Potential for harm · Dcited before2025-02-04 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure 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 follow the facility's posted menu for residents on a pureed diet for 3 of 7 residents (R5, R12, R19) reviewed for pureed diets in the sample of 13. The findings include: A facility list dated 2/2/25 showed R5, R12, and R19 received a pureed diet. The facility's lunch menu dated 2/2/25 showed residents were to be served servings of ham, spinach au gratin, sweet potatoes, a dinner roll, and pineapple cake. On 2/2/25 at 11:48 AM, R5's lunch tray was placed in front of him. Food items on his tray included pureed ham, spinach, sweet potatoes, and cake. No pureed roll or bread item was noted on his tray. At 12:20 PM, R5 was being fed by facility staff. No pureed roll or bread item was noted on his tray. On 2/2/25 at 12:21 PM, R12 and R19 were seated in the dining room being fed their pureed lunch by facility staff. No servings of a pureed roll or bread were noted on R12's or R19's lunch tray. On 2/2/25 at 1:15 PM, V3 Dietary Manager stated residents on pureed diets should receive the same food items as residents 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.
- Potential for harm · Dcited before2024-07-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an injury of unknown origin to the abuse coordinator for one of three residents (R2) reviewed for abuse in the sample of eight. The findings include: R2's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety disorder, rheumatoid arthritis, and age related osteoporosis. R2's Care Plan created February 27, 2023 shows R2 should be checked for any physical marks or injuries and care for injuries according to protocol and when observing or suspecting an incident of abuse and neglect would be reported to the abuse coordinator immediately and follow protocol. On July 2, 2024 at 11:18 AM, V5 CNA (Certified Nursing Assistant) said R2 had a mark to her forehead. V5 said the mark was a red line at first but eventually it turned into a bruise. V5 said she told R2's nurse about the mark on her forehead. V5 said that if she sees a bruise on a resident, then she tells her nurse right away.…
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.
- Potential for harm · Dcited before2024-07-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 repositioned in bed in a safe manner for one of three residents (R1) reviewed for safety in the sample of eight. The findings include: R1's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including congestive heart failure, dementia, chronic obstructive pulmonary disease, muscle contractures, major depressive disorder, muscle weakness, and need for assistance with personal care. R1's Care Plan started March 30, 2021 shows R1 is on anti-platelet medication and is at risk for bruising easily and bleeding. Added June 14, 2024: bruising right inner thigh, right leg, right hand, left forearm, left hand, left upper thigh. March 30, 2021 notify medical doctor of any excessive bleeding or bruising. Report anything that may have happened to resident that may cause bruise. R1's Care Plan started March 30, 2021 shows R1 is at risk for bruising due to fragile skin, has a history of chronic bruises related to diagnoses…
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.
- Potential for harm · Dcited before2024-04-30 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 submit a final investigation report to IDPH (Illinois Department of Public Health) within 5 days. This applies to 3 of 3 residents (R1, R2, R3) reviewed for abuse in the sample of 7. The findings include: R1's initial Incident Investigation Report was submitted to IDPH on 2/16/24. IDPH did not receive a final report from the facility. R2's initial Incident Investigation Report was submitted to IDPH on 2/21/24. IDPH did not receive a final report from the facility. R3's initial Incident Investigation Report was submitted to IDPH on 2/26/24. IDPH did not receive a final report from the facility. On 4/30/24 at 11:26AM, V1 (Administrator) stated, I normally submit my reports online but for some reason it wasn't working. I tried to send it and the screen went black. I did not notify anyone at IDPH that I was having difficulties submitting the reports. I also tried to fax the reports to IDPH, but I didn't check to make sure that the fax number was correct or that the fax went through. I also did not verify with IDPH that they…
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.
- Potential for harm · Dcited before2024-04-30 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 a thorough investigation of alleged abuse, failed to maintain records of an abuse investigation. These failures apply to 3 of 7 residents (R1, R2, R3) reviewed for abuse in the sample of 7. The findings include: R1, R2, and R3's Incident Investigation Report Final Summary showed the facility failed to interview the accused staff members, failed to identify any other residents at risk for abuse, failed to interview residents to ensure they felt safe in the facility, and failed to interview employees working on the same shift as the accused staff members. On 4/30/24 at 11:26AM, Surveyor requested abuse investigation files for R1, R2, and R3. Surveyor received abuse investigation files at 2:26PM. V1 stated, I don't keep them in a file, I just jot down notes in my notebook. On 4/30/24 at 2:27PM, V1 (Administrator) stated, I am the interim Administrator and have been here since January 2024. I developed the abuse binder that shows staff what steps need to be taken for any allegation of abuse. As the abuse coordinator,…
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.
- Potential for harm · Fcited before2024-01-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 ensure dishwasher temperatures were at the proper level for sanitation, and failed to ensure food temperatures were maintained at 135 degrees Fahrenheit prior to serving. This failure has the potential to affect the 37 of 39 residents who receive food and beverages from the facility's kitchen. The findings include: The CMS (Centers for Medicare and Medicaid Services) 671 form titled Long-Term Care Facility Application for Medicare and Medicaid, dated 1/16/24, showed 39 residents resided in the facility. The list of residents and their diets, provided by the facility on 1/18/24, showed 2 residents are NPO (take nothing by mouth). On 1/16/24 at 11:08 AM, V23 (Dietary Cook) finished making the pureed pork loin for the lunch meal. V23 took the container and lid used to puree the pork loin into the dishwashing area, rinsed them and place them into a rack to send through the dishwasher. V24 (Dietary Services Manager) went in with V23 and this…
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.
- Potential for harm · Fcited before2024-01-18 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to identify, implement, and document control measures to prevent the growth of opportunistic waterborne pathogens (such as Legionella); failed to establish acceptable ranges for control measures; and failed to identify corrective actions for when control limits are not met. This applies to all residents residing in the facility. The findings include: The facility's CMS 671 dated 1/16/24 showed 39 residents resided in the facility. On 1/17/24 at 10:28 AM, the surveyor requested the facility's Legionella Water Management Program from V4 (Infection Preventionist). V4 looked at the surveyor blankly and stated, I'm not sure if I'm involved in that. I don't know anything about that. I know [V6 - Maintenance Director] checks water temperatures, but that's about it. At 1:02 PM, V4 provided an undated Water Management Program document. This document was the outline of what a facility should do to develop a program but did not contain any facility specific information about the facility's potential areas of legionella…
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.
- Potential for harm · E2024-01-18 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 ensure a medication cart was locked when not in sight of the nurse. This has the potential to affect 5 of 5 residents (R9, R12, R30, R31, R34) reviewed for medication storage in the sample of 12, and 14 residents (R1, R4, R6, R7, R11, R13, R14, R15, R18, R22, R24, R26, R28, and R193) outside the sample. The findings include: 1. On 1/17/24 at 9:13 AM, the medication cart for the C/D halls was in the common walking area, between the nursing station and the halls. V18 (Registered Nurse-RN) walked away from the medication cart and entered the first room on the right down the hall. The keys to the medication cart were in the lock on the medication cart. At 9:14 AM, V18 exited the room and walked back to the medication cart. At 9:15 AM, V18 said she should not have left the keys in the medication cart because someone could have opened the medication cart and taken whatever they wanted. On 1/18/24 at 10:28 AM, V7 (RN) and V4 (Infection Preventionist/Wound Nurse) said it is not acceptable for the keys to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-18 · tag F0803 — failed to meet residents' dietary needs — patternEnsure 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 ensure residents receiving a pureed diet received a dinner roll during the lunch meal for 2 of 2 residents (R31, R39) reviewed for pureed diets in the sample of 12 and 3 residents (R7, R19, R37) outside the sample. The findings include: On 1/16/24, from 10:30 AM-11:40 AM, V23 (Dietary Cook) was observed making the pureed foods for the lunch meal service. At 11:19 AM, V24 (Director of Dietary Services) came into the area and put a sheet pan with dinner rolls on them into the oven. On 1/16/24 from 12:17 PM-12:44 PM, R7, R19, R31, R37, and R39 were observed in the dining room eating lunch. All these residents had a pureed diet. None of these residents received a pureed dinner roll for the lunch meal. On 1/17/24 at 2:42 PM, V24 (Director of Dietary Services) said the residents that are on pureed diets should have received pureed dinner rolls because it is part of their approved menu. The list of residents and their diets, provided by the facility on 1/18/24, showed R7, R19, R31, R37, and R39 as the residents 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.
- Potential for harm · D2024-01-18 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 protect the confidential health information for 1 of 1 resident (R30) reviewed for privacy in the sample of 12. The findings include: On 1/17/24 at 9:13 AM, the medication cart for the C/D halls was in the common walking area, between the nursing station and the halls. V18 (Registered Nurse-RN) walked away from the medication cart and entered the first room on the right down the hall. R30's electronic medical record was visible on the computer screen located on the medication cart. At 9:15 AM, V18 said she should not leave a resident's medical record open when she is away from the cart. On 1/18/24 at 10:28 AM, V7 (Registered Nurse/MDS Coordinator) and V4 (Wound Nurse/Infection Preventionist) said it is important to lock the computer so no one can see a resident's medical record; for the resident's privacy and rights. On 1/18/24 at 10:31 AM, V2 (Director of Nursing-DON) said the computer should be put on walkaway feature when the nurse is not by the cart because it covers the medical record, and it is not able…
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.
- Potential for harm · Dcited before2024-01-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 calling a resident's physician when blood glucose levels are out of a specified range for 1 of 2 residents (R30) reviewed for quality of care in the sample of 12. The findings include: R30's face sheet, provided by the facility on 1/18/24, showed she had diagnoses including type 2 diabetes mellitus without complications, Exocrine pancreatic insufficiency (a condition in which the pancreas does not release enough digestive enzymes. As a result, the body cannot properly digest food and absorb nutrients. The endocrine pancreas makes the hormone insulin, which helps to control blood sugar levels), long term use of insulin, and adult failure to thrive. R30's facility assessment dated [DATE] showed she is cognitively intact. On 1/18/24 at 8:35 AM, R30 was in her room, lying in bed. R30 was alert and oriented. R30 said her blood sugar levels are high sometimes. R30 said the nurses update her doctor. R30 said she…
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.
- Potential for harm · Dcited before2024-01-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide wound care in a manner to prevent cross-contamination, failed to wash hands during wound care, and failed to provide weekly wound assessments for 1 of 3 residents (R34) reviewed for pressure injuries in the sample of 12. The findings include: R34's Physician's Order Report showed an order dated 1/9/24 for: Wound Order-Abdomen -Medial midline: Cleanse wound, and peri wound with wound cleanser; apply skin prep to peri wound; apply mupirocin to wound vase; cover with AG dressing (calcium alginate dressing) moistened with saline; cover with 2 x 2 gauze, cover and secure with Opti foam gentle dressing. Change dressing every other day. R34's facility assessment dated [DATE] showed she had a stage III pressure injury that was present on admission or reentry into the facility. On 1/17/24 at 9:50 AM, V4 (Wound Nurse) performed hand hygiene, then gathered the supplies needed to perform a dressing change for the pressure ulcer on R34'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.
- Potential for harm · D2024-01-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to notify a resident's Power of Attorney (POA) after an incident occurred for 1 of 3 residents (R1) reviewed for notifications in the sample of 7. The findings include: On 1/4/23 at 11:49 AM, V4 (Nurse Practitioner - NP) said she was providing care to R1 while he was in the hospital. V4 said V5 (R1's POA) expressed concerns with R1's care at the facility. V4 said V5 was unable to provide specific details but told her that R1 had injured his foot a few months ago when the facility used the wrong scale to weigh him. V4 said V5 had a large bruise to his left foot, and no one called her to report the injury. V4 said R1 is weak and had not been out of the bed while he was in the hospital. R1's progress note dated 10/18/23 at 6:54 PM showed, Resident reported to this writer that while being weighed earlier today staff bumped his toe on the scale while positioning him. His left great toe has a small red area on the tip of his toe, only uncomfortable…
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.
- Potential for harm · Dcited before2024-01-09 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed report a resident-to-resident physical altercation to the state agency for 1 of 3 residents (R3) reviewed for resident-to-resident abuse in the sample of 7. The findings include: On 1/5/24 at 11:30 AM, R3 was sitting up in her wheelchair. R3 said back in September she was sitting at the end of [NAME], watching TV. R3 said R7 came in and started arguing with her over the TV remote. R3 said R7 attacked her and scratched her arm. R3 said there wasn't any staff in the area at the time it happened. R3's Skin Integrity Events -- Scratches dated 9/23/23 showed R3 had an argument with another resident over a TV remote control, resulting in a bleeding scratch to her left forearm. This document showed R3 experienced moderate pain, rated at a 4 on a 1-10 pain scale. R3's Progress Notes dated 9/23/23 at 6:45 PM showed, Resident was allegedly attacked by another resident due to TV remote control. Resident sustained a minor cut to her left forearm, bleeding ceased, band…
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.
- Potential for harm · Dcited before2024-01-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to conduct a thorough investigation of a resident-to-resident physical altercation for 1 of 3 residents (R3) in the sample of 7. The findings include: On 1/5/24 at 11:30 AM, R3 was sitting up in her wheelchair. R3 said back in September she was sitting at the end of [NAME], watching TV. R3 said R7 came in and started arguing with her over the TV remote. R3 said R7 attacked her and scratched her arm. R3 said there wasn't any staff in the area at the time it happened. R3's Skin Integrity Events -- Scratches dated 9/23/23 showed R3 had an argument with another resident over a TV remote control, resulting in a bleeding scratch to her left forearm. This document showed R3 experienced moderate pain, rated at a 4 on a 1-10 pain scale. R3's Progress Notes dated 9/23/23 at 6:45 PM showed, Resident was allegedly attacked by another resident due to TV remote control. Resident sustained a minor cut to her left forearm, bleeding ceased, band aid applied. DON notified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 safely weigh a resident (R1) and failed to provide adequate supervision for residents involved in a resident-to-resident physical altercations (R3, R7) for 3 of 4 residents (R1, R3, R7) reviewed for safety and supervision in the sample of 7. The findings include: 1. On 1/4/23 at 11:49 AM, V4 (Nurse Practitioner - NP) said she was providing care to R1 while he was in the hospital. V4 said V5 (R1's POA) expressed concerns with R1's care at the facility. V4 said V5 was unable to provide specific details but told her that R1 had injured his foot a few months ago when the facility used the wrong scale to weigh him. V4 said V5 had a large bruise to his left foot, and no one called her to report the injury. V4 said R1 is weak and had not been out of the bed while he was in the hospital. On 1/4/24 at 2:46 PM, V6 (CNA) said the CNAs obtain the residents weights. V6 said if the resident used a walker, then they are a sit to stand. V6 said there 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.
- Potential for harm · D2023-12-12 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 a resident received the correct dose of long-lasting insulin resulting in a significant medication error. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's Face Sheet showed R1 was a type 2 diabetic. On 12/12/23 at 9:19 AM, V1 (Administrator) said V8 (Registered Nurse- RN) made a medication error resulting in R1 receiving more insulin than what was ordered. On 12/12/23 at 11:12 AM, V8 said on 12/3/23 she mistakenly gave R1 35 units of glargine (long lasting insulin) when R1 was to get 8 units. V8 said the error occurred because she was looking at R2's orders when preparing R1's insulin. R1's Physician Order Report showed R1 was to get 8 units of glargine. R2's Physician Order Report showed R2 was to get 35 units of glargine. The facility's Medication Error Report showed R1 received the wrong dose of insulin. On 12/12/23 at 11:00 AM, V7 (R1's Doctor) said based on the type of drug involved in the medication error, R1 could have had erratic blood sugars and/or…
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.
“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.
- 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.
Fines & penalties
$18,450 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $18,450 — penalty dated 2026-02-26
- Medicare payment denial — starting 2025-02-26 for 114 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COUNTY OF STEPHENSON | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/21/2014 |
| MCGLYNN, SUZANNE | Individual | W-2 MANAGING EMPLOYEE | — | since 10/12/2012 |
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.
About 84% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
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 145895. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, 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.