Gilman Healthcare Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

38.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 81 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 5.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 38 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 99 beds and averages 55.7 residents a day — about 56% occupied, or roughly 43 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 3.12 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.64 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 2.80 hrs/resident/day on weekends vs 3.25 on weekdays — 14% thinner on weekends. RN hours go from 0.72 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.

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

Inspection trend

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.

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

Inspection deficiencies

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

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.

26 citations, most serious first. The 16 most serious are shown; the remaining 10 are one tap away and print in full.

• Immediate jeopardy · J2023-09-01 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to develop a care plan and interventions for a resident (R4) who is at high risk for developing pressure ulcers and has a history of pressure ulcers. The facility failed to implement pressure relieving interventions, routinely assess resident's skin, identify a pressure ulcer, assess a pressure ulcer upon identification, report a pressure ulcer to the wound nurse and physician, implement a treatment, and ensure open wounds were covered for one (R4) of five residents reviewed for pressure ulcers and repositioning in the sample list of five. These failures resulted in R4 developing a pressure ulcer of the right buttock that deteriorated into a Stage 4 pressure ulcer without treatment nor interventions. The Immediate Jeopardy began on (8/17/23) when R4 developed a pressure ulcer that was not identified, evaluated, and treated. V1 (Administrator) was notified of the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to adequately assess and supervise a cognitively impaired resident for the use of an electric assisted standing recliner for one (R1) of three residents reviewed for accidents on the sample list of five. This failure resulted in R1 falling and receiving a left subdural hematoma and a nondisplaced fracture of the left frontal bone. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment, needed substantial assistance with Activities of Daily Living (ADL), wheelchair bound and dependent on staff to and unable to ambulate. R1's Fall Risk Evaluation dated 11/16/24 documents R1 was at risk for falls. R1's Care Plan dated 11/26/24 documents; Fall Risk: R1 has the potential for falls due to current medical conditions and Gait/Balance problems, Restorative: R1 has limited physical mobility related to weakness. R1's Chair/bed-to-chair transfer Task dated 12/13/24 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure all mechanical lift slings were routinely assessed and replaced in accordance with manufacturer's instructions and facility policy. This failure resulted in a mechanical lift sling breaking during R1's transfer which caused R1 to fall from the mechanical lift and sustain head lacerations that required staple closure. This failure has the potential to affect seven additional residents (R2, R3, R4, R5, R6, R7, R8) of eight residents reviewed for mechanical lift transfers in the sample list of eight. Findings include: The facility's Safe Resident Handling/Transfers policy dated December 2023 documents residents require safe handling during transfers to prevent/minimize risk for injury and staff will inspect equipment prior to use. This policy documents if equipment is damaged, broken, or not functioning properly the equipment will be removed from further use. This policy documents manufacturer's instructions on proper sling sizing and tracking of service times will be followed, slings will be…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-10-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to prevent two episodes of physical abuse between residents for five of five residents (R1, R2, R8, R9 and R10) reviewed for abuse on the sample list of 10. This resulted in R1 hitting R2 on top of the head with a metal cane then R1 throwing a cup and eating utensils at R2, hitting R2 in the arm, causing psychosocial harm for R2 and R9, along with a hematoma to the top of R2's head. Findings Include: The facility's Abuse, Neglect and Exploitation Policy dated 2/28/23 documents, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse include, but is not limited to hitting, slapping, punching, biting and kicking. The facility's Final Incident Report dated 9/22/23 documents on 9/17/23, it was reported that…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop care plans and implement fall prevention interventions for residents at risk for falls and failed to thoroughly investigate a fall and implement appropriate post fall interventions for three of three residents (R5, R6 and R7) reviewed for falls on the sample list of 10. These failures resulted in R5 having multiple falls resulting in a compression fracture of L5. Findings Include: The facility Fall Prevention Program dated June 2023 documents the fall prevention program will be implemented to ensure all resident's safety in the facility whenever possible. This program should include a measure that determines each resident's needs by assessing the risks for falls and implementing appropriate interventions to provide the necessary supervision, and assistive devices are utilized as necessary. As part of the initial assessment, identify with a history of falls and risk factors for subsequent falling. Risk factors causing the fall…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-07-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility staff failed to provide safety for one resident (R21) when using the mechanical lift for transfer for one (R21) of four residents reviewed for accidents in a sample of 23. This failure resulted in R21 falling onto the floor out of of a mechanical lift sling during a transfer requiring a emergency department evaluation and sustaining a facial laceration. Findings include: The Physician's Orders dated July 2023 list the following diagnosis for R21: Obstructive Hydrocephalus, Unspecified Dementia with Behavior Disturbance, Bipolar and Seizures. Facility incident report dated 6/19/2023 documents R21 was being transferred with a mechanical lift by V7, CNA (Certified Nursing Assistant). R21 was up in the air above the bed in the mechanical sling and the strap broke which caused R21 to fall out of the sling and was assisted to the floor by V7. R21 hit his head, left temple area on the leg of the mechanical lift and received a laceration to left eyebrow and skin tear to left hand along with a large area of bruising the the left hand and arm.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-05-24 · tag F0868 — widespread
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview the facility repeatedly failed to ensure that a designated key member (Infection Control Preventionist) of the committee was present at their quarterly Quality Assurance (QA) meeting. This has the potential to affect all 56 residents that reside in the facility. Findings include: On 5/21/24 at 3:25 pm the facility provided an undated facility Quality Assurance and Performance Improvement Program (QAPI) policy that documents the following: The facility Administration is responsible to oversee that the facility to ensure Quality Assurance and Performance Improvement Committee (QAPI) , meet monthly at minimum and includes the following key members: The facility Director of Nursing, Medical Director or other designated Physician, Infection Control Preventionist, Staff responsible for the facility plant and three additional staff member responsible for direct patient care and services. The facility provided the attendance sign-in sheets with the QAPI policy noted above. The sign in sheets included all QA committee meetings held since last annual…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-05-24 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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 provide Activities of Daily Living (ADL's) assistance, to maintain residents dignity for two of 25 residents (R25 and R46) reviewed for dignity on the sample list of 25. Findings include: 1.) R46's Diagnoses Sheet dated 3/19/24 documents the following diagnoses: Unspecified Dementia, Unspecified Severity With Agitation, Cognitive Communication Deficit, Unspecified Lack of Coordination, and Difficulty in Walking Not Elsewhere Classified. R46's Minimum Data Set (MDS) dated [DATE] documents R46's Brief Interview of Mental status score of four out of a possible 15, which indicates severe cognitive impairment. The same MDS does not document any behaviors directed to self or others. R46's Care Plan dated 3/19/24 documents the following: Resident has an ADL (Activity of Daily Living) Deficit, Self-care performance deficit r/t (related/to) impaired balance. Intervention: Encourage the resident to participate to the fullest extent possible with each…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-05-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to routinely provide oral hygiene for one of one resident (R25) reviewed for oral care on the sample list of 25. Findings Include: The facility's Oral Care policy dated 4/2/24 documents it is the facility's practice to provide oral care to residents in order to prevent and control plaque-associated oral disease. R25's Medical Diagnoses List dated May 2024 documents R25 is diagnosed with Palliative Care, Depression, Alzheimer's Disease, Dementia, Mood Disorder, and Restlessness and Agitation. R25's Minimum Data Set, dated [DATE] documents R25 is severely cognitively impaired and requires substantial/maximum assist for oral hygiene. R25's Care Plan dated 5/23/24 documents R25 is not accepting of oral care and is verbally and physically abusive towards staff during this task. On 5/21/24 at 12:09 PM R25's teeth appeared filled with food debris. Her gums were reddened and appeared inflamed. On 5/23/24 at 11:49 PM R25's teeth appeared filled with…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-05-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to maintain a resident toilet and bed position remote control cable in a safe and repaired condition. These failures have the potential to affect three residents (R4, R14, R31) of four reviewed for safety in the sample list of 25. Findings include: 1. R4's diagnosis list (5/24/2024) documents diagnoses including: Difficulty in Walking, Intellectual Disabilities, Morbid Obesity, and Dementia. R4's quarterly assessment (3/28/2024) documents R4 uses a walker for mobility and is frequently incontinent of bowel and bladder. R4's Fall Risk Assessment (3/28/2024) documents R4 has poor vision, is ambulatory, and has balance problems when standing. R4's Care Plan (5/23/2024) documents R4 is at risk for falling. On 5/21/2024 at 1:35PM, R4 reported using the shared toilet located between R4's room and the adjacent resident room. R4 reported being concerned about the toilet moving around when R4 sits on the toilet and R4 reported having to sit very still while using the toilet to keep the toilet from moving. R4 reported the…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-10-23 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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 answer a call light timely for one of four residents (R4) reviewed for call lights/delay in care on the sample list of six. Findings Include: R4's MDS (Minimum Data Set) dated 8/21/23 documents R4 is alert and oriented. On 10/18/23 at 10:32 am, R4 stated it takes a long time for staff to answer R4's call light and explained that R4 had waited as long as an hour in the past for the call light to be answered. On 10/19/23 at 8:23 am, R4's call light was activated. At 8:30 am, V10 Scheduler walked by R4's room and did not answer the call light. R4 can be heard across the hall and approximately 20 feet away breathing hard and grunting. At 8:34 am, V10 then walked past R4's room again without stopping and entered the office next door to R4's room, grabbed a wheelchair and then exited the office, again walking past R4's room without answering the call light. At 8:38 am, V10 and V2 DON (Director of Nursing) both walked past R4's activated call light without answering it. At 8:39 am, V10 and V2 both walked by active…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-10-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation, interview and record review, the facility failed to perform timely toileting assistance for one of three residents (R4) reviewed for toileting on the sample list of six. Findings Include: R4's MDS (Minimum Data Set) dated 8/21/23 documents R4 is alert and oriented and requires assistance with toileting. On 10/19/23 at 8:23 am, R4's call light was activated. At 8:48 am, staff answered R4's call light then left the room. At 8:50 am, R4 stated, R4 was waiting for staff to toilet R4 explaining, I (R4) have to go bad and I have been waiting for them to take me since 8:10 am (40 minutes). At 8:55 am, V11 and V12 CNA's (Certified Nursing Assistant's) returned to R4's room to toilet R4. Both stated 40 minutes is a long time to wait to use the restroom however there was only three staff on the unit providing cares and that R4 requires two staff due to using a mechanical lift.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on observation and interview, the facility failed to properly perform incontinence care for one of three residents (R2) reviewed for toileting and incontinence care on the sample list of six. Findings include: On 10/18/23 at 12:40 pm, V6 and V7 CNA's (Certified Nursing Assistant's) entered R2's room to provide incontinence care. R2 was lying in bed. R2 was incontinent of urine. V7 performed cares, using a soapy washcloth, wiping R2 from back to front multiple times, then repeated the same motion with a rinse cloth and towel. After incontinence care was completed, V7 stated V7 always wipes residents from back to front. The facility Perineal Care Policy dated 6/1/23 documents it is the practice of this facility to provide perineal care to all incontinent residents to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. Staff are to clean buttocks and anus, wipe front to back; vagina to anus in females using a separate washcloth or wipes.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-10-16 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop 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 operationalize their Abuse, Neglect and Exploitation Policy for reporting and investigating abuse allegations for five of five residents (R1, R2, R8, R9 and R10) reviewed for abuse on the sample list of 10. Findings Include: The facility Abuse, Neglect and Exploitation Policy dated 2/28/23 documents it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focus the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause. The facility will have written…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-16 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to report an allegation of physical abuse between two residents (R1, R2) reviewed for abuse on the sample list of 10. Findings Include: On 10/12/23 at 12:23 pm, V12 LPN (Licensed Practical Nurse) stated V12 was told by V8 Activity Aide/CNA (Certified Nursing Assistant) that R1 threw R1's cups at R2 and hit R2 in the arm. On 10/12/23 at 12:39 pm, V8 stated last week when V8 was in the dining room, V8 walked by R2's table and R2 reported that R1 had just thrown a glass and silverware at R2, hitting R2 in the arm. V8 stated V8 considered R1's actions to be abusive towards R2, so V8 reported the situation to administration and wrote up a witness statement. V8's witness statement dated 10/5/23 documents R2 reported to V8 that R1 had just thrown a cup and silverware from R1's table to R2's; of which the cup hit R2 on R2's upper, outer left arm. R2 stated R2 was not hurt and apparently no one else was hurt at the table as a result of R1's action. On 10/12/23 at 2:15 pm, V1 Administrator stated V1 was not aware of R1 throwing items…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond 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 investigate an allegation of physical abuse between two residents (R1, R2) reviewed for abuse on the sample list of 10. Findings Include: On 10/12/23 at 12:39 pm, V8 stated last week while in the dining room, R2 reported to V8 that R1 threw a glass and silverware at R2, hitting R2 in the arm. V8 stated V8 reported the situation to administration and wrote a witness statement due to V8 considering R1's actions to be abusive in nature toward R2. V8's witness statement dated 10/5/23 documents R2 reported to V8 that R1 had just thrown a cup and silverware from R1's table to R2's; of which the cup hit R2 on R2's upper, outer left arm. R2 stated R2 was not hurt and apparently no one else was hurt at the table as a result of R1's action. On 10/12/23 at 2:15 pm, V1 Administrator stated V1 was not aware of R1 throwing items toward R2 and hitting R2 with said items on 10/5/23 until approximately 10 minutes ago, due to being out of the facility. At this time, V2 DON (Director of Nursing) stated after V2 was told about the situation,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$168,256 in federal fines across 4 penalties.

• $21,764 — penalty dated 2025-07-08
• $17,101 — penalty dated 2024-01-23
• $48,540 — penalty dated 2023-10-16
• $80,851 — penalty dated 2023-09-01

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

Part of a chain

This home belongs to PREMIER HEALTHCARE OF ILLINOIS — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

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. This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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