Galena Stauss Nursing Home
215 Summit Street, Galena, IL 61036 · Non profit - Other · 57 certified beds · (815) 776-7254 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)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Oct 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 4 actual-harm citations
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 35.5% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.6% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 6.3% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.5% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 5.8% | 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 | 7.4% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 30.6% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.5% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.1% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.9% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 36.2% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.0% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 14.3% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 7.7% | 63.1% | 79.4% | worse |
‡ 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 0.02 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. 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 data for this measure is missing or was not submitted. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality 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 57 beds and averages 35.7 residents a day — about 63% occupied, or roughly 21 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 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.46 hrs/resident/day on weekends vs 4.27 on weekdays — 19% thinner on weekends. RN hours go from 1.32 to 0.80 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
31 citations, most serious first. The 14 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2026-06-29 · 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 transport a resident in a wheelchair in a safe manner for 1 of 4 residents (R2) reviewed for transport in the sample of 7. This failure resulted in R2 falling forward from the wheelchair and sustaining a femur fracture. The findings include:R2's Care Plan shows R2 is alert and oriented with activities of daily life self-care performance deficits related to osteoarthritis to bilateral knees, chronic pain, weakness, edema, activity intolerance, and osteoporosis. On 6/29/26 at 10:42 AM, V6 Activity CNA said she was with several residents on an outing to a local superstore. V6 said R2 had finished her shopping and V6 was pushing R2 in her wheelchair out of the threshold of the door of the store. V6 said she was looking straight ahead of R2 at some other residents that were in front, when she heard V7 Auxiliary Volunteer said Oh! V6 said when she looked down R6 was falling forward out of the wheelchair. V6 said she was unable to stop R2 from falling. V6 said R2 did not have footrests on her wheelchair. V6 said R2 landed on her…
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 before2025-12-03 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide a restorative program for a resident with limited mobility. This failure resulted in R22 experiencing a decline in mobility. This applies to 1 of 6 residents (R22) reviewed for range of motion/mobility in the sample of 17. The findings include: R22's admission Record dated 12/2/25, shows she was admitted to the facility on [DATE], with diagnoses including osteoarthritis, abnormalities of gait and mobility, morbid obesity, pain in right knee, localized edema, and anxiety disorder. An order for physical therapy was entered on June 25, 2025. On 12/1/25, at 10:57 AM, R22 was observed sitting in her wheelchair. R22 said she is not able to stand. R22 said she does exercises when the exercise room is opened, but it's not opened every day. R22 said when the exercise room is opened, she does exercise to her right leg which is her weaker leg. R22 said no one walks her in the facility. R22 said facility staff have to use the stand lift 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.
- Actual harm · G2025-12-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to obtain and monitor weights for a resident (R6) with recent significant weight loss. The facility failed to inform the dietician of a decreased oral intake for a resident (R6) with recent significant weight loss. The facility also failed to notify the dietician that a resident's (R7) nutritional supplement was discontinued. These failures contributed to R6 and R7's continued weight loss. This applies to 2 of 3 residents (R6, R7) reviewed for weight loss in the sample of 17.The findings include: 1.R6's care plan revised on 7/21/24 showed R6 was at risk for weight loss related to her diagnosis of Multiple Sclerosis. The plan showed R6 required staff assistance to complete all activities of daily living. R6 was cognitively intact. R6's Weight Summary report showed R6 weighed 237.5 lbs (pounds) on 8/12/25, 218.9 lbs on 9/24/25 and 206 lbs on 11/5/25. The report showed no documented weight in October 2025 for R6. The report showed R6 sustained a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-09-04 · 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 observation, interview, and record review the facility failed to safely transfer a resident with a hoist mechanical lift, which resulted in the resident falling from the hoist and sustaining a cervical spine (neck) fracture. This applies to 1 of 3 (R1) residents reviewed for falls in the sample of the 3. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 1/31/23 with diagnoses to include partial left and right leg amputation; 2 diabetes; and mild cognitive impairment. R1's 8/6/24 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS showed R1 was depenedent upon staff for transfers from the bed to chair. On 9/3/24 at 9:05 AM, R1 stated she had a fall a few weeks prior; however, R1 was unable to recall the details of the fall. R1 stated soon after the fall she began experiencing neck pain. On 9/3/24 at 9:05 AM, R1 was in her geri-chair with a cervical (neck) brace in place. R1's left temple had a faint blue/purple color similar to a nearly…
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 before2026-06-29 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
Based on observation, interview and record review the facility failed to ensure residents were treated with respect for 4 of 6 residents (R1, R3, R4, R7) reviewed for respect in the sample of 7. The findings include: On 6/29/26 at 9:45 AM, R1 was sitting in her wheelchair at the nurse's station. R1 said she has problems with the night Certified Nursing Assistant (CNA) V10. R1 said V10 acts like she is mad at her. R1 said she had her call light on to be changed and V10 came in and said she would be back and then never came back to help her. On 6/29/26 at 11:02 AM, R4 was sitting in her wheelchair in her room. R4 said V10 has turned off her call light saying she would come back and then never did. R4 said she thinks V10 went home and forgot about her. On 6/29/26 at 11:20 AM, R3 was sitting in her recliner in her room. R3 said she needs help transferring to the wheelchair and help with incontinence care. R3 said V10 has a cocky attitude and is lazy. R3 said V10 does half the job and leaves a mess for the other CNA. R3 said V10 has come in and turned her light off saying she would be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-26 · 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 resident's (R1) allegation of sexual abuse to Illinois Department of Public Health (IDPH) and local law enforcement. This applies to 1 of 3 residents reviewed for abuse reporting in the sample of 3.The findings include:R1's electronic face sheet printed on 3/26/26 showed R1 has diagnoses including but not limited to congestive heart failure, type 2 diabetes, Alzheimer's disease, dementia with behaviors, major depressive disorder, and schizotypal disorder.R1's facility assessment dated [DATE] showed R1 refused to have her cognitive status assessed. During interview with R1 on 3/26/26, surveyor determined R1 is alert and oriented to person, place, and time.R1's care plan dated 12/18/25 showed, (R1) does have an Alzheimer's dementia diagnosis and does report experiencing visual hallucinations as well as long held delusions. (R1) does experience agitation and has displayed combative behaviors; however, her behaviors have improved greatly over 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 · Dcited before2026-03-11 · 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 interview and record review, the facility failed to schedule a follow up dental visit for a resident (R1) experiencing oral pain. This applies to 1 of 3 residents reviewed for quality of care in the sample of 6. The findings include:R1's electronic face sheet printed on 3/11/26 showed R1 has diagnoses including but not limited to congestive heart failure, Type 2 diabetes, Alzheimer's disease, major depressive disorder, hypertension, and schizotypal disorder.R1's facility assessment dated [DATE] showed R1 has no cognitive impairment and experiences delusions.On 3/10/26 at 12:56PM, R1 stated, I went to the dentist last month and they said I need 4 teeth extracted on the top of my mouth. They didn't do any x-rays or cleaning. Ibuprofen helps with the pain and takes it all away. When I went to the hospital they gave me antibiotics but I had a reaction to it. They said maybe I had an infection and that's why it was hurting so they ordered an antibiotic to cover it. I had a follow up appointment scheduled…
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 before2025-12-03 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review the facility failed to provide a facility assessment. This applies to all 34 residents residing in the facility. The findings include:The long-term care facility application for Medicare and Medicaid dated 12/1/25 shows, there are 34 residents residing in the facility. On 12/3/25 at 11:40 AM, V1 Administrator stated she could not find her completed facility assessment. V1 did provide a facility assessment tool kit that did not have any facility information in it. The facility provided paper on 12/3/25 shows, Facility Assessment: Completed: 11/28/2024 however, there was no completed assessment. On 12/3/25 at 2:25 PM, V1 Administrator stated, she did not have a facility assessment policy. The facility did not provide a policy on the facility assessment.
- Potential for harm · Dcited before2025-12-03 · 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 ensure a dressing was in place to an open wound. This applies to 1 of 17 residents (R22) reviewed for quality of care in the sample of 17.The findings include: R22's admission Record shows she was admitted to the facility on [DATE], with diagnoses including osteoarthritis, diabetes mellitus, morbid obesity, localized edema, and venous insufficiency. R22's Order Summary Report dated 12/3/25 shows an order was entered 6/25/25 for, Sodium chloride external solution. Apply to bilateral lower extremities two times a day. Cleanse bilateral lower extremities venous stasis ulcers with 50/50 vinegar and normal saline. Apply nonadherent gauze, abdominal dressing (as needed for drainage), and kerlix wrap. On 12/1/25 at 10:57 AM, R22 was observed sitting in her wheelchair. There was a large open wound to R22's left knee area that was about two inches by two inches. The wound had a yellowish wound bed. There was no dressing in place to this wound. R22…
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 before2025-12-03 · 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 observation, interview and record review the facility failed to supervise residents during medication administration to prevent a medication administration error. The facility failed to ensure a resident was transferred in a safe manner. This applies to 2 of 17 residents (R3, R28) reviewed for safety and supervision in the sample of 17.The findings include:1.R3's current care plan showed R3 was severely cognitively impaired related to her diagnosis of dementia.R3's Incident Notes dated 10/31/25 showed, While giving medication to tablemate (R17), resident (R3) grabbed the pills and water and started taking the other residents pills. The notes showed R3 ingested R17's medications which included Bumex (diuretic medication) 1 mg (milligram), Entresto 24/25 mg (blood pressure medication), Rexulti 0.5mg (antipsychotic), Rosuvastatin 10 mg (cholesterol medication), and Spironolactone 25 mg (diuretic). The notes showed R3's physician was notified of the incident. R3 was monitored by facility staff. R3 had no adverse outcome from the medication ingestion. On 12/1/25 at 11:29 AM, V3…
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 before2025-12-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 ensure a resident's cannabidiol (CBD) medication was securely stored and inaccessible to a resident for 1 of 17 residents (R2) reviewed for medication storage in the sample of 17.The findings include:On 12/1/25 at 9:50 AM, R2 was seated in bed. A small silver tin container, covered with a lid labeled Extra Strength 1500 mg (milligram) CBD Balm, was noted on R2's bedside table. R2 pointed to the CBD balm and stated, I put that on my back and knees when they hurt. When R2 was asked how much balm does she apply with each application, R2 stated, However much I want. On 12/2/25 at 9:56 AM, R2 was asleep in bed. R2's tin of CBD balm remained on her bedside table.On 12/2/25 at 9:08 AM, V4 Registered Nurse (RN) stated R2 cannot self-administer any of her medications because R2 is confused on and off.On 12/2/25 at 11:59 AM, V1 Administrator stated, We do allow residents to receive CBD products here if they are prescribed. A resident will need a physician order for the CBD for us to be able to administer it.On 12/3/25 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 · Dcited before2025-12-03 · 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 implement Enhanced Barrier Precautions (EBP) for 2 of 17 residents (R6, R16) reviewed for infection control in the sample of 17.The findings include:A facility list dated 12/1/25 showed R6 was on Enhanced Barrier Precautions due to her having wounds to her buttocks and having a urinary catheter in place. The list showed R16 was also on EBP due to her having a urinary catheter in place.1.On 12/1/25 at 11:50 AM, R6 was in bed. An Enhanced Barrier Precautions (EBP) sign was noted on the door to R6's room. The sign showed staff were to wear a protective gown, gloves, and mask when providing high contact cares to R6. An isolation cart containing PPE (personal protective equipment) was noted in the hallway by the entrance to R6's room. At 11:52 AM, V5 Certified Nursing Assistant (CNA) entered R6's room to provide cares. V5 donned a mask and gloves upon entering R6's room but did not don a gown. From 11:52 AM-12:32 PM, V5 CNA provided a bed bath to R6, without donning a protective gown, which included cleansing 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 · D2024-10-17 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was free from sexual abuse. This applies to 1 of 3 residents (R2) reviewed for abuse in the sample 3. The findings include: The facility's Incident Report dated 10/13/24 documents R1 was groping R2's breast. V7 (Agency CNA-Certified Nursing Assistant) witnessed R1 groping R2's breast in the dining room. R1's face sheet shows he is an [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, atrial fibrillation, major depressive disorder and metabolic encephalopathy. R2's face sheet shows she is a [AGE] year-old female with diagnoses including ischemia cardiomyopathy, hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, heart failure, aphasia, and dementia. On 10/16/24 at 9:38 AM, R1 was observed in his room lying in bed. He was alert to self, he was confused to the month and year. R1 could not recall the incident…
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 · F2024-10-03 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to submit quarterly reports to the Payroll-Based Journal (PBJ). This failure has the potential to affect all residents in the facility. The findings include: The facility's roster dated 10/1/24 showed 44 residents residing in the building. The facility's PBJ report dated April 1-June 30, 2024 showed, Failed to submit data for the quarter. On 10/2/24 at 10:03AM, V1 (Administrator) stated, I was made aware that this data was not submitted and there is no reason why. Our corporate staff usually submit it but for some reason they just didn't. We have already received our notification in the mail from IDPH (Illinois Department of Public Health) regarding this so I already knew about the issue. We don't have any policy regarding the PBJ reporting.
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- Potential for harm · Fcited before2024-10-03 · 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 interview and record review, the facility failed to implement their policy regarding Legionella management. This failure has the potential to affect all residents in the building. The findings include: The resident census report dated 10/1/24 showed 44 residents currently residing in the building. On 10/3/24 at 9:38AM, V1 (Administrator) stated, I have been working with (hospital infection preventionist) on our policy but we don't have any plan set yet. We don't have any of the water management program done yet, just the hospital one. We have no diagrams, surveillance process, or testing process completed or initiated yet. If we had a Legionella outbreak, we would probably not have any idea of where to even start looking as we haven't implemented anything yet. On 10/3/24 at 10:37AM, V3 (Infection Preventionist) stated, We have not done anything with legionella that I am aware of. I believe the plan is in process, but we haven't implemented anything yet. The facility's undated policy titled, Legionella and Waterborne Pathogens Policy showed, Objective: I. To establish a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-03 · 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 interview and record review the facility failed to assess non-pressure wounds, failed to have treatments in place for wounds, and failed to notify the physician of new wounds. This applies to 2 of 2 residents (R10 & R41) reviewed for wound care in the sample of 13. The findings include: 1. R10's admission Record (Face Sheet) showed he was admitted to the facility on [DATE]. R10's 7/11/24 Skin/Wound Note from 6:45 PM showed, Dime size areas noted on coccyx (tail bone area) with cares. Area cleansed and [protective ointment] applied for MASD (Moisture Associated Skin Damage). (The note does not document a wound bed description, measurements, or if any notifications made.) R10's 7/16/24 Skin/Wound Note from 6:56 AM showed, Open area to right buttocks. Crease of buttocks. Cleansed area with soap and water and applied [foam bandage]. Shower aid found area. 1cm (centimeter) by 3cm. Will report to next shift to contact POA (Power of Attorney) and PCP (Primary Care Provider). Will continue to monitor. (Five…
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 · D2024-10-03 · 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
Based on observation, interview, and record review the facility failed to assess a pressure injury, failed to treat a pressure injury, and failed to notify the physician of a pressure injury. This applies to 1 of 2 residents (R10) reviewed for pressure injuries in the sample of 13. The findings include: On 10/02/24 at 10:15 AM, V4 Registered Nurse (RN) removed R10's adult brief exposing an approximately 1-centimeter (cm) round, non-draining, wound to his right, upper, inner buttock. The area surrounding the wound appeared friable and inflamed. V4 provided a wound treatment and covered the wound with a 4-inch foam dressing. R10's 8/6/24 Skin/Wound Note from 6:58 PM showed, New [foam dressing] placed on upper gluteal crease. Dated for today. Area of concern is clean, no drainage, looks to be a stage 2 [pressure injury]. R10's 8/6/24 Skin/Wound Note from 7:02 PM showed, Wound measures: 0.8cm x 0.4cm, depth is approximately 2mm (millimeter). R10's 8/9/24 Skin/Wound Note from 8:49 PM showed, [Foam dressing] changed to upper gluteal crease. One open area remains, 0.5cm in diameter, 0.2cm…
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 before2024-10-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 oxygen tubing was replaced monthly for 2 of 4 residents (R7, R24) reviewed for oxygen in the sample of 13. The findings include: 1. R7's face sheet showed an [AGE] year-old female with diagnosis of obstructive sleep apnea, osteoporosis, heart failure, chronic kidney disease stage 3, fibromyalgia, and hypertension. On 10/01/24 at 09:26 AM, R7 was seated in her room. R7 had an oxygen tubing in her nostrils. The oxygen was administered at 3 liters (l) per hour per nasal cannula (nc) via concentrator. There was no date on the tubing to indicate how long it was in use. On 10/1/24 at 9:26 AM, R7 said she wears her oxygen all the time. On 10/02/24 at 11:41 AM, V3 Infection Preventionist said it is important to change oxygen tubing monthly to avoid moisture and bacteria buildup. There should be a physician order on the care and maintenance of the tubing, so it populates to the resident treatment or administration record. We can't…
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 · D2024-10-03 · 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
Based on interview and record review the facility failed to have licensed staff administer medicated powder. The applies to 1 of 1 residents (R10) reviewed for pharmacy services in the sample of 13. The findings include: R10's 7/11/24 Physician Communication note from 2:09 PM showed Situation: resident red/yeasty groin. R10's Order Summary Report (Physician Order Sheet) showed an order for Nystatin Powder, apply to groin topically as needed for excoriated areas in groin. The order was started 7/11/24. R10's 7/16/24 skin/wound note from 6:56 AM showed, Open area to right buttocks. Crease of buttocks. Cleansed area with soap and water and applied [foam dressing]. Shower aid found area. 1cm (centimeter) by 3cm. Will report to next shift to contact POA (Power of Attorney) and PCP (Primary Care Provider). Will continue to monitor. R10's 7/20/24 skin/wound note from 10:51 AM showed, AM CNA (Certified Nursing Assistant) put treatment powder to [R10's] buttocks. This RN (Registered Nurse) unable to view as he is in the recliner chair. Will attempt to look at it when he is toileted if I am…
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 before2024-10-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect a resident (R40) from a significant medication error. This applies to 1 of 8 residents observed in the medication pass. The findings include: R40's electronic face sheet printed on 10/2/24 showed R40 has diagnoses including but not limited to type 2 diabetes, venous insufficiency, chronic kidney disease, and acute embolism and thrombosis of left lower extremity. R40's facility assessment dated [DATE] showed R40 has no cognitive impairment, has diabetes, and receives insulin. R40's care plan dated 6/11/24 showed, (R40) does have a diagnosis of diabetes mellitus. Diabetes medications as ordered by doctor. R40's physician's orders dated 9/21/24 showed, Lantus Subcutaneous Solution (Insulin Glargine) Inject as per sliding scale: If 100-280= 10 units morning and bedtime; 281-500= 25 units morning and bedtime. Follow same orders for noon and evening blood sugar. On 10/1/24 at 11:56AM, V5 (Licensed Practical Nurse-LPN) stated, (R40'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 · Dcited before2024-10-03 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 store 2 residents (R9,R12) controlled medications under a double lock system. This applies to 2 of 2 residents outside of the sample reviewed for controlled medication storage. The findings include: R9's physician's orders dated 9/23/24 showed, Lorazepam oral concentrate 2mg/ml give 0.2ml sublingually every 1 hour as needed for agitation . R12's physician's orders dated 9/21/24 showed, Lorazepam oral concentrate 2mg/ml give 0.2ml sublingually every 1 hour as needed for anxiety . On 10/3/24 at 10:00AM, V6 (Licensed Practical Nurse) unlocked the medication room and opened the medication refrigerator that had no lock on it. Inside of the medication refrigerator were 1 unopened and 1 partially used bottle of lorazepam with R9's name on them. Another partially used bottle was in the refrigerator with R12's name on it. R9 and R12's lorazepam bottles were not under any additional locks in the medication refrigerator. On 10/3/24 at 10:05AM, V6 stated, Lorazepam has always been stored in this refrigerator and we have…
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 · D2024-09-04 · 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
Based on interview and record review the facility failed to notify R1's physician of new-onset neck pain following a fall from a hoist mechanical lift. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 1/31/23 with diagnoses to include partial left and right leg amputation; type 2 diabetes; and mild cognitive impairment. R1's 8/6/24 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. On 9/3/24 at 9:05 AM, R1 stated she had a fall a few weeks prior; however, R1 was unable to recall the details of the fall. R1 stated soon after the fall she began experiencing neck pain. R1 stated it took at least a week before she was sent out for X-rays following her fall. R1 stated she believed the facility should have notified her provider of the neck pain sooner than they did. R1's Serious Injury Incident Report submitted on 8/21/24 showed, CNA (Certified Nursing Assistant) report (V3) 8/12/24…
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 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 interview and record review the facility failed to ensure residents were treated with dignity and respect for 2 of 5 residents (R2 and R3) reviewed for resident rights in the sample of 5. The findings include: 1. On 4/30/24 at 11:20 AM, R2 said that she had an issue with V3 (Registered Nurse) two Sundays ago. R2 said that the new person in the room next to her was having her family bring in a rug and she didn't feel that that was appropriate due to being a trip hazard. R2 said that V3 came to give her with evening medications and she questioned her about the rug and V3 turned bright red, put her hand up in my face to gesture stop and said very loudly, I don't know who gave them permission, it's not your concern. She was not speaking to me in a very dignified manner and I didn't appreciate it. All she had to say is I'm not sure but I will look into it and move on. R2's Minimum Data Set assessment dated [DATE] shows that her cognition is intact. 2. On 4/30/24 at 12:15 PM, R3 said that she has had issue…
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 · D2024-04-30 · 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
Based on interview and record review the facility failed to implement their abuse policy by not immediately protecting a resident from the alleged perpetrator after an alleged abuse for 1 of 6 residents (R1) reviewed for abuse in the sample of 6. The findings include: On 4/30/24 at 10:01 AM, V4 (Registered Nurse-RN) said that on Thursday 4/25/24 around 7 or 8 PM, she was doing a narcotic count with V3 (RN) and V5 (Licensed Practical Nurse-LPN). V4 said that R1 was sitting near the nurse's station as she usually does. V4 said that she had her back to R1 when she heard a commotion so she turned around and she saw V3 grab an ice cream out of R1's hand and throw it away. V3 then took a tissue and angrily gave it to R1 and said, Clean yourself up and then said, We are not doing this sh tonight. V4 said that she is not sure what provoked the response because R1 was having a good day. V4 said that she didn't want to make it worse for anyone so she did not say or do anything and continued with narcotic count with V3 and V5 and left. V4 said that she thought about the incident over 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 · 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 ensure a staff member immediately reported an alleged abuse the the administrator for 1 of 1 resident (R1) reviewed for abuse reporting in the sample of 6. The findings include: On 4/30/24 at 10:01 AM, V4 (Registered Nurse-RN) said that on Thursday 4/25/24 around 7 or 8 PM, she was doing a narcotic count with V3 (RN) and V5 (Licensed Practical Nurse-LPN). V4 said that R1 was sitting near the nurse's station as she usually does. V4 said that she had her back to R1 when she heard a commotion so she turned around and she saw V3 grab an ice cream out of R1's hand and throw it away. V3 then took a tissue and angrily gave it to R1 and said, Clean yourself up and then said, We are not doing this sh tonight. V4 said that she is not sure what provoked the response because R1 was having a good day. V4 said that she didn't want to make it worse for anyone so she did not say or do anything and continued with narcotic count with V3 and V5 and left. V4 said that she thought about the incident over the weekend and decided to email V1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-31 · 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 ensure the safety and supervision of a resident who went through alarmed doors and eloped from a facility on the night shift for 1 of 3 residents reviewed (R1) for safety and supervision in the sample of 4. The findings include: The Incident Note dated 10/12/23 at 11:05 for R1 showed, Resident exited facility, getting outside and fell, which was witnessed by CNA (Certified Nursing Assistant) responding to alarm but unable to reach resident before he fell. Minor injuries-cuts and abrasions. Moves all extremities without difficulty and/or pain. Assisted up and into facility by CNA and this nurse. Neuro's and Vitals assessed. See vitals documentation. Wound care to injuries. The facility's Incident Report for R1 dated 10/13/23 to Illinois Department of Public Health showed, CNA Post Fall Investigation Report for R1 for the incident date of 10/12/23. The description of the event on the report showed, Just finished rounds down shining star hallway. I went to the dining room to find the nurse. As we were talking a door alarm went…
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 before2023-10-12 · tag F0838 — failed to assess facility resources and resident needs — widespreadConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to develop and maintain a facility assessment. This failure has the potential to affect all residents in the facility. The findings include: The Resident Census and Condition Report dated 10/10/23 showed 44 residents residing in the building. On 10/11/23 at 10:46AM, V1 (Administrator) stated, We do not have a facility assessment; I know we are supposed to have one and I am learning how to do it. We are doing research on exactly what we need to be doing so we can ensure we have the correct number of staff and that those staff are trained on any specialized needs our resident's might have.
- Potential for harm · Ecited before2023-10-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
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 obtain physician's orders for a resident (R8) to utilize a CPAP (Continuous Positive Airway Pressure) machine, failed to obtain physician's orders for 3 resident's (R8,R23,R33) CPAP pressure settings, failed to perform routine respiratory assessments for 3 resident's (R8,R23,R33) who utilize a CPAP machine, failed to store 4 resident's (R8,R23,R27,R33) CPAP machines in a manner to prevent contamination. These failures apply to 4 of 5 resident's reviewed for CPAP therapy in the sample of 14. The findings include: 1) R8's electronic face sheet printed on 10/11/23 showed R8 has diagnose including but not limited to Diagnosis: unspecified cirrhosis of liver, type 2 diabetes, ascites, obstructive sleep apnea, and herpes viral ocular disease. R8's facility assessment dated [DATE] showed R8 has no cognitive impairment and requires the use of a non-invasive mechanical ventilator (CPAP). R8's physician's orders dated 10/11/23 showed, Clean CPAP…
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 · D2023-10-12 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 dignity bag was in place over an indwelling urinary catheter drainage bag for 1 of 1 residents (R6) reviewed for dignity in the sample of 14. The findings include: On 10/10/23 at 11:57 AM, R6 was in the dining room in her wheelchair with a indwelling urinary catheter drainage bag attached under her wheelchair. The drainage bag was half full of urine and there wasn't a dignity bag in place over the drainage bag during the lunch time meal service. On 10/11/23 at 9:50 AM, V4 LPN (Licensed Practical Nurse) stated catheter drainage bags should have dignity bags over them whenever the resident with a catheter leaves their room. On 10/11/23 at 10:01 AM, V2 DON (Director of Nursing) stated the facility has catheter drainage bag covers that are to be used all of the time when a resident is out of their room and out in the facility. V2 stated the drainage bag covers are used to maintain the dignity of the resident. The Diagnosis Report dated 10/11/23 for R6 showed medical diagnoses including multiple sclerosis,…
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 before2023-10-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure restorative programs including ROM (range of motion) were being provided regularly for 2 of 5 residents (R6 & R33) reviewed for range of motion in the sample of 14. The findings include: 1. On 10/10/23 at 9:41 AM, R6 was sitting in a custom wheelchair in her room with a mechanical lift sling under her. R6 had a positioning device on the left side of her upper body and a neck pillow in place. R6 stated she doesn't get ROM exercises anymore because there isn't enough staff to do it. R6 stated she used to go to the therapy room and use the hand pulleys to exercise her arms. R6 stated she used to go to the group exercises but that stopped too. R6 stated the programs stopped about a month ago. The Diagnosis Report dated 10/11/23 for R6 showed medical diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, anemia, hyperlipidemia, hematuria, urinary tract infection, and diverticulitis.…
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 before2023-10-12 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent a significant medication error for 1 of 1 residents (R36) reviewed for medication errors in the sample of 14. The findings include: R36's electronic face sheet printed on 10/12/23 showed R36 has diagnoses including but not limited to Alzheimer's disease, hypertension, major depressive disorder, hyperlipidemia, type 2 diabetes, anxiety disorder, and mood disorder. R36's facility assessment dated [DATE] showed R36 has severe cognitive impairment. R36's physician's orders showed R36 had Amlodipine 5mg daily ordered on 11/16/22 and was discontinued on 9/30/23. R36's nursing progress notes dated 9/28/23 showed, (R36) was eating her supper meal when suddenly she became warm, clammy, and unresponsive for a short period of time. Blood pressure 70/46 .Staff escorted (R36) to her room and laid her down in bed. Notified primary physician regarding the incident. He diagnosed the incident as postprandial hypotension. He recommended to monitor her 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.
“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
No federal fines in the current CMS record. 2 Medicare payment denials on record.
- Medicare payment denial — starting 2026-04-14 for 66 days
- Medicare payment denial — starting 2025-12-01 for 46 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 |
|---|---|---|---|---|
| MIDWEST MEDICAL FOUNDATION | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 04/25/2019 |
| WAMSLEY, MARIE | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 05/12/2014 |
| HEY, DAVID | Individual | CORPORATE DIRECTOR | — | since 01/01/2013 |
| HOLLAND, JOEL | Individual | CORPORATE DIRECTOR | — | since 05/02/2017 |
| KILGORE, HELEN | Individual | CORPORATE DIRECTOR | — | since 01/01/2007 |
| LORENZEN, JOHN | Individual | CORPORATE DIRECTOR | — | since 05/02/2017 |
| MILLER, ROBERT | Individual | CORPORATE DIRECTOR | — | since 01/01/2009 |
| SHEAHEN, MARY | Individual | CORPORATE DIRECTOR | — | since 01/01/2012 |
| SLOAN, BARBARA | Individual | CORPORATE DIRECTOR | — | since 05/02/2017 |
| THOMPSON, GARRY | Individual | CORPORATE DIRECTOR | — | since 12/01/2013 |
| TOEPFER, VINCE | Individual | CORPORATE DIRECTOR | — | since 01/01/2008 |
| WRABL, CAROL | Individual | CORPORATE DIRECTOR | — | since 01/01/2008 |
| BAUER, TRACY | Individual | CORPORATE OFFICER | — | since 01/26/2009 |
CMS files one row per role, so the 14 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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 146140. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-03, 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.