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Evercare of Granite City

3500 Century Drive, Granite City, IL 62040 · For profit - Limited Liability company · 86 certified beds · (618) 877-2700 Medicare & Medicaid certified

Call the home — (618) 877-2700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 2025Behavioral-health or dementia-care citation at the harm level (F0744)3 actual-harm citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$32,523 in federal fines
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
  • it has 3 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $32,523 in federal fines (most recent 2025-06-26)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (78%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3717 Nameoki Rd Ste B · (618) 876-2438 · Call to confirm hours
Pharmacy
Walgreens0.6 mi
3732 Nameoki Rd · (618) 877-6880 · Call to confirm hours
Grocery
3801 Nameoki Rd · (618) 451-8150 · Call to confirm hours
Park
Rode Park0.6 mi
1540 Amos Ave · (618) 452-6213 · Typically dawn to dusk
Place of worship
1014 W Pontoon Rd · (618) 451-7884

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 4 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased29.9%13.4%15.4%worse
Long-stay residents who lose too much weight9.5%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.4%1.5%2.0%better
Long-stay residents with depressive symptoms30.8%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.1%3.3%better
Long-stay residents whose ability to walk worsened23.0%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication23.1%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine98.7%91.8%95.3%typical
Long-stay residents with pressure ulcers7.1%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control8.1%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.0%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine83.1%63.1%79.4%typical
Short-stay residents rehospitalized after admission18.2%26.1%22.6%better
Short-stay residents with an outpatient ER visit9.5%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days1.642.021.67typical
Long-stay outpatient ER visits per 1,000 resident days3.522.221.80worse

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.

45.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.9%U.S. median 51.5%
Got home and stayed home
12.4%U.S. median 10.7%
Went back to hospital
63.6%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 63.6% 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 22 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 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.9%CMS range 35.0–60.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.4%CMS range 8.2–17.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge50.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge54.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.5%CMS range 5.3–16.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.371.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.35
RN hours/ resident / day
0.64
LPN hours/ resident / day
1.45
Aide hours/ resident / day
2.45
Total nurse hours/ resident / day
0.33
RN hoursweekends
78.3%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 86 beds and averages 81.1 residents a day — about 94% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.45 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 2.00 hrs/resident/day on weekends vs 2.63 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.36 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 78% is well above the national median of 45%. 1 administrator has left in the past year.

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

2
deficiencies at the latest standard inspection (2025-09-19)
3
at the previous standard inspection (2024-10-18)

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.

ABCDEFGHIJKL

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

21 citations, most serious first. The 14 most serious are shown; the remaining 7 are one tap away and print in full.

  • Actual harm · G2025-12-08 · tag F0744 — failed to care for residents with dementia — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    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 care for a dementia resident in a safe manner for 1 of 2 resident (R2) reviewed for abuse in the sample of 10. This failure resulted in R2 sustaining a left humerus fracture. Findings include:Based on interview and record review, the facility failed to care for a dementia resident in a safe manner for 1 of 2 resident (R2) reviewed for abuse in the sample of 10. This failure resulted in R2 sustaining a left humerus fracture. Findings include:R2's admission Record, print date of 12/1/25, documents R2 was admitted on [DATE] with diagnoses of Osteoarthritis and Dementia. R2's Minimum Data Set, dated [DATE], documents R2 is severely cognitively impaired, is dependent on staff for toileting, lower body dressing, chair to bed transfer, is incontinent of bowel and bladder, and has no behaviors. R2's Care Plan, Date Initiated: 05/27/2025, documents, Resident has some memory loss and impaired decision making ability. Dx (diagnosis) dementia. Resident can 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 · Gcited before2025-06-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to prevent abuse for 6 out of 8 residents, (R1, R2, R3, R5, R6, R7) reviewed for abuse in a sample of 8. This failure resulted in R2 being hit in the face resulting in a bruised chin, feeling uncomfortable and R5 feeling unsafe in the facility. Findings include: 1. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, that he has delusions, verbal behavioral symptoms directed towards others occurring daily, rejection of care occurred daily, and wandering occurred daily. R1's MDS continued to document that R1's current behavior status has worsened. R1's Care Plan dated 4/9/25 documented R1 has potential to be physically aggressive related to anger and poor impulse control with interventions placed on 4/9/25 to administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing…

    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 before2025-06-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent a resident-to-resident altercation for 2 of 5 (R2, R3) residents investigated for abuse. This failure resulted in R3 sustaining a minimal fracture to the left nasal bone. This past non-compliance occurred from 4/30/25 to 5/13/25. Findings include: 1.R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE]. R2's EMR dated 1/3/25 documents a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R2's EMR dated 5/6/25 documents a diagnosis of unspecified psychosis not due to a substance or known physiological condition. R2's MDS (Minimum Data Set) dated 4/8/25 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS does not document that the resident had any verbal, physical, or other behaviors. The MDS documents that the resident was independent with roll left and right, sit to lying, and lying to sitting on side of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2025-04-03 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to notify the nurse of a resident having a change in condition to ensure timely assessment for 1 of 4 residents (R3) reviewed for quality of care in the sample of 5. This failure resulted in R3 not having timely assessment and subsequently having a Hypoxic/Unresponsive episode, with Cardiopulmonary Resuscitation (CPR) started, and was hospitalized . The Findings Include: R3's admission Record, dated [DATE], documents R3 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. R3's diagnoses includes Chronic Obstructive Pulmonary Disease (COPD), Arteriosclerotic Heart Disease (ASHD), Cardiomyopathy, Myocardial Infarction (MI), Morbid Obesity, Hyperlipidemia, Anemia, Sleep Apnea, Hypertension (HTN), and a Coronary Artery Bypass Graft (CABG). R3's Baseline Care Plan, dated [DATE], documents R3 was alert cognitively, is a fall risk, and the receives special treatment: Oxygen. R3's Minimum Date Set (MDS), dated…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement progressive interventions to reduce falls for 2 out of 9 (R12, R53) residents investigated for accidents in a sample of 34.1. R12's Electronic Medical Record (EMR) undated documents the resident was admitted to the facility on [DATE] and has a medical diagnosis of Parkinson's Disease with Dyskinesia, Dementia, and Alzheimer's Disease. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired, has an upper and lower extremity on both sides, and needs substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transfers. R12's Care Plan Date Initiated 5/23/2025 documents R12 has an increased risk for falls related to impaired mobility, Parkinson's, Cerebrovascular Accident, Hypertension, Alzheimer's, history of falls, Osteoarthritis, incontinence, Bipolar, Anxiety, Major Depressive Disorder with use of psychotropic medication. No new…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-09-19 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise care plans with progressive intervention following falls for 2 out of 9 (R12, R53) residents investigated for accidents in a sample of 34.1. R12's Electronic Medical Record (EMR) undated documents the resident was admitted to the facility on [DATE] and has a medical diagnosis of Parkinson's Disease with Dyskinesia, Dementia, and Alzheimer's Disease. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired, has an upper and lower extremity on both sides, and needs substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transfers. R12's Care Plan Date Initiated 5/23/2025 documents R12 has an increased risk for falls related to impaired mobility, Parkinson's, Cerebrovascular Accident, Hypertension, Alzheimer's, history of falls, Osteoarthritis, incontinence, Bipolar, Anxiety, Major Depressive Disorder with use of psychotropic medication.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility allowed Certified Nursing Assistants (CNA) to administer Oxygen to residents for 1 of 4 residents (R3) reviewed for administration of Oxygen (O2) in the sample of 5. The Findings Include: R3's admission Record, dated 3/18/25, documents R3 was admitted to the facility on [DATE] and was discharged to the hospital on 3/7/25. R3's diagnoses includes Chronic Obstructive Pulmonary Disease (COPD), Arteriosclerotic Heart Disease (ASHD), Cardiomyopathy, Myocardial Infarction (MI), Morbid Obesity, Hyperlipidemia, Anemia, Sleep Apnea, Hypertension (HTN), and a Coronary Artery Bypass Graft (CABG). R3's Baseline Care Plan, dated 2/27/25, documents R3 was alert cognitively, is a fall risk, and receives special treatment: Oxygen. R3's Minimum Date Set (MDS), dated [DATE], documents R3 was cognitively intact and dependent on staff for toileting, dressing, and transfers, substantial/moderate assistance with showers and partial/moderate assistance for all other Activities of…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-10-18 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 76 residents living in the facility. Findings include: On 10/15/24 at 8:30 AM, tour of the kitchen was conducted. In the walk-in refrigerator was a roll out cart and on the tray were clear drinks, and pink colored drinks. There were 24 (4 ounce) plastic glasses that had no date and/or label on them. On 10/15/2024 at 8:32 AM, V12, Dietary Manager stated, We just made those drinks today. They should have dated and labeled them. I would expect everything to have a date and label so there is no guessing of when it was made. On 10/15/2024 at 8:33 AM, in the dry storage area is a large, industrial, 72-quart clear container of a whitish brown colored medium grain substance. It is not dated and/or labeled. On 10/15/2024 at 8:34 AM, V12 stated the container contained rice and it should have been dated and labeled. On 10/15/2024 at 8:35 AM, was another 72-quart container, halfway full, containing…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-18 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent resident to resident abuse for 2 of 7 residents (R29 and R42) reviewed for abuse in the sample of 31. Findings include: 1. R42's Physician Order Sheet for October 2024 documents, Unspecified dementia, severity with behavior disturbances, unspecified dementia, unspecified severity, with agitation, unspecified psychosis not due to a substance or known physical condition, bipolar disorder, major depression, anxiety disorder, Alzheimer disease, insomnia, essential hypertension, allergic rhinitis, GERD, cognitive communication deficit, and adult failure to thrive. R42's Minimum Data Set, dated [DATE] documents R42 was cognitively intact for decision making for activities of daily living. R42's Care Plan with problem onset date of 2/9/2024 Diagnosis of bipolar, MDD (major depressive disorder), anxiety, and benefit from the use of psychotropic medication. I exhibit attention seeking behaviors/inappropriate behaviors such as pacing up and down halls,…

    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 · Dcited before2024-10-18 · 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 ensure a safe transfer for 1 of 5 residents (R64) reviewed for transfers in the sample of 31. Findings include: R64's Physician Order Sheet (POS) dated October 2024 documents a diagnosis of Down's syndrome, hypothyroidism, major depressive disorder, dysphagia, oral phase, other symptoms and signs with cognitive functions and awareness. R64's Care Plan, with a problem onset date of 11/1/2023, documents, I have a diagnosis of MDD (mental depressive disorder) and benefit from the use of psychotropic medication. I have diagnosis of Down's syndrome, Alzheimer/dementia, I am nonverbal and unable to communicate my needs. R64's Minimum Data Set (MDS) dated [DATE] documents R64 was severely impaired for cognition for activities of daily living. Dependent on staff, helper does all of the effort for most activities. On 10/16/2024 at 4:14 PM, V13, Certified Nursing Assistant (CNA) was pushing a mechanical lift down the hallway. She entered R64's room…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-31 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to respect the resident's rights to receive packages and mail unopened. This failure has the potential to affect all 72 residents residing in the Facility. Findings include: 1. On 8/29/2023 at 1:15 PM, R41 stated, I've had 6 or 8 letters opened and amazon packages opened multiple times. Maybe they thought they were opening (R41's name)'s mail. That's how it was explained to me. The package (that was opened) is what really psed me off. It was just coffee and sugar, not like it was heroin. On 8/31 at 11:25 AM, R41 stated, I had a Wal-Mart and Amazon package opened. Best guess is they mixed it up. There is a shipping label on the package and you could see it had been taped back up with clear tape. It really boggles my mind. It looked like someone put some real effort into opening it. The Amazon package looked like it was cut open with a razor. I know I'm not the only one but I don't remember who else had it happen. I just heard about it in passing. 2. On 8/29/2023 at 1:20 PM R37 stated, I have had letters open when I got them…

    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 · F2023-08-31 · tag F0732 — widespread
    Post nurse staffing information every day.
    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 the daily nursing staff posting was current for 2 of 4 days of the survey. This failure has the potential to affect all 72 residents residing in the facility. Findings include: On 08/28/23 at 08:30 AM, an observation was made of the daily nursing staff posting, dated 08/21/23, located inside of the main entrance doors. It documents there were currently 72 residents residing in the facility at the start of the shift. It specified the Registered Nurses, (RNs), and Licensed Practical Nurses, (LPNs), work 12-hours shifts but did not specify the times of the shifts. It did not specify the times or shifts the Certified Nursing Assistant, (CNAs), were to work. On 08/29/23 at 11:04 AM, and observation was made indicating the daily nursing staff posting had not been changed. On 08/29/23 at 11:15 AM, V1, Administrator stated the daily staffing should be updated every day. V1 said she currently doesn't have anyone to update the sheet but she will get it changed. The Resident Census and Conditions of Residents…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-31 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to remove expired medications from the medication cart; failed to store Tuberculin (TB) Solution at the proper temperature; failed to discard the TB solution after 30 days as documented on the TB solution box in 1 of 2 medication carts inspected. Medications were left on three different resident's bedsides tables (R6, R15, R54) during med pass. This failure has the potential to affect all 72 residents residing at the facility. Findings included: 1. On 08/28/23 at 09:45 AM, The medication cart on the 200 hallway was inspected. The medication cart contained the following: 1. A bottle of Folic Acid 400mcg with an expiration date of 04/23. 2. A bottle of Vitamin B12 100mcg with an expiration date of 06/23. 3. A bottle of Geri Dryly allergy relief 25mg with an expiration date of 04/23. 4. A bottle of TB solution located in the medication drawer with an open date of 05/03/23. The package documents, store at 35 degrees to 46 degrees Fahrenheit (F),…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-31 · 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 interview and record review the facility failed to ensure that all required Professional Department Heads were present at their Quality Assurance meetings at least quarterly. This failure has the potential to affect all 72 residents residing in the facility. Findings include: On 8/31/2023 the Facility's Monthly Facility Quality Assurance, (QA), and Meeting Minutes from January 2023 through August 2023 were reviewed. There was only one month, (June), that had been signed by V14, Medical Director, (MD). V11 Infection Preventionist, (IP), was not listed or included on any of the forms. On 8/31/2023 at 9:30 AM, V22 stated, she oversees the Quality Assurance Program and they meet monthly. V22 stated, I will go through them with you, (the Monthly Facility Quality Assurance and A Minutes). Is (V11, Infection Preventionist) supposed to be on this form? There is infection control stuff on here but the DNS, (Director of Nursing Services, V2), puts it into the minutes. You're right. There is only one (month signed by V14). The Monthly Facility QA and A form is dated 7/30/2022, but V22…

    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
Show the remaining 7 citations
  • Potential for harm · E2023-08-31 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide assistance with grooming and hygiene to dependent residents for 5 of 8 residents (R7, R21, R24, R51, R57) observed for Activities of Daily Living, (ADL), in the sample of 32. Findings include: 1. R7's Face sheet, undated, documents, R7 was admitted to the facility on [DATE]. R7's Medical Diagnosis, Chronic Obstructive Pulmonary Disease, (COPD), Alzheimer's Disease, Dementia, Arteriosclerotic heart disease, (ASHD), Major Depressive Disorder, Anemia, Hypertension, (HTN), Alcohol Dependence, and Cognitive Communication Deficit. R7's Care Plan, dated 7/26/23, documents, R7 is at risk for skin issues related to, impaired mobility, Alzheimer's/Dementia, Incontinence. R7 has frequent rashes to my groin, due to my hygiene practices. Encourage me to take my showers and to have proper hygiene, provide me preventative treatment to my groin as ordered. It continues R7 requires assist with some ADL related to, impaired mobility, Diagnosis…

    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 · E2023-08-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    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 — 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 timely and complete incontinent care for 4 of 5 (R7, R15, R59, R65) residents, reviewed for incontinent care in a sample of 32. Findings includes: 1. On 08/30/2023 from 10:00 AM until 1:20 PM, using 15-minute intervals, R59 was up to her wheel chair in an activity and then was taken out to the dining room for lunch. At 1:10 pm R59 head was lowered towards the dining room table. A staff member was sitting next to R59 assisting another resident with eating. At 1:15 PM, R59 was taken out of the dining room, by a staff member and placed at the nurse's station. At 1:20 PM V14, Certified Nurse Assistant, (CNA), took R59 into her room and R59 stated she was tired. V14 stated she was not able to check R59 because she was busy taking care of and getting other residents up for therapy. V14, CNA unfastened R59's urine-soaked adult incontinent brief and with the same gloved hands, took several disposable wipes and cleansed R59 abdominal fold…

    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 · E2023-08-31 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to perform appropriate hand hygiene and glove changes for 4 of 6 (R15, R34, R59, R65) residents observed for infection control, in a sample of 32. Findings include: 1. On 08/30/2023 at 1:20 PM V14, Certified Nurse Assistant, (CNA), took R59 into her room, donned gloves without benefit of hand hygiene. V12, Licensed Practical Nurse, (LPN), entered R59's room, donned gloves without benefit of hand hygiene. V14 was able to unfasten R59's urine-soaked adult incontinent brief, and with the same gloved hands, took several disposable wipes and cleansed R59 abdominal fold and labia. V12, LPN and V14, CNA, with the same gloved hands laid R59 to her left side. V14 took another hand full of disposable wipes and in a circular motion cleansed R59 right buttock, vaginal and rectal area with the same wipes and without benefit of hand hygiene or glove change. V14 then removed the urine-soaked adult incontinent brief and threw it on to the floor and placed a…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-31 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and observations, the facility failed to provide a call light that was within reach of the resident for 3 of 18 residents (R5, R7, R48) reviewed for call lights in the sample of 32. Findings include: 1. R48's diagnoses include Alzheimer's Disease, Dementia, Major Depressive Disorder, Hyperlipidemia, Hypertension, (HTN), Gastroesophageal Reflux Disease, (GERD), Cognitive Communication Deficit. R48's Care Plan, dated 8/21/23, documents R48 is at increased risk for falls, related to left hip fracture status post fall, HTN, MDD, (Major Depressive Disorder) /Insomnia with use of Psychotropic medication, Alzheimer's/Dementia. Interventions: Place call light and frequently used items within safe reach. R48's Minimum Data Set, (MDS), dated [DATE], documents R48 is cognitively intact with a Basic Interview for Mental Status (BIMS) of 14. R48 requires supervision with set up assist for bathing. R48 is independent for all other Activities of Daily Living, (ADLs). R48 is always continent of both bowel…

    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 · D2023-08-31 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide privacy for 1 of 6 residents (R15) reviewed for incontinent care in a sample of 32. Findings include: On 08/29/2023 at 9:35 AM, V6, Certified Nurse Assistant, (CNA), and V7, CNA unfastened R15's adult incontinent brief, exposing R15's penis, groin, abdominal fold. After incontinent care, V6 doffed her gloves, V6 then performed hand hygiene in R15's bathroom and donned gloves, leaving R15's penis and groin expose. V6 and V7 both CNAs, performed incontinent care to R15's peri rectal and buttock area and when it was complete V6 and V7, both doffed their gloves and performed hand hygiene in the bathroom. R15's private areas were left exposed. Care plan dated 07/2023 documented, provide me skin care after any incontinent episode. On 08/31/2023 at 9:10 AM V4, CNA stated she would provide privacy during incontinent care by covering up the resident up. On 08/31/2023 at 9:15 AM, V17, CNA stated she would provide privacy during incontinent care by covering up the resident up. On 08/30/2023 at 3:45 PM, V2,…

    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 · D2023-08-31 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to follow up with hospital orders and clarify the need for an antibiotic for 1 of 4 (R33) residents reviewed for unnecessary mediations in the sample of 32. Findings include: The Facility's Infection Control Log dated 8/1/2023-8/25/2023 documents, R33 had a urinary infection, no culture was performed and R33 was prescribed an antibiotic. R33's Progress Notes 8/1/2023 documents, R33's suprapubic catheter became clogged and R33 was sent to the local hospital. R33's Urinalysis dated it was collected 7/31/2023. It further documents R33's urine had >100,000 mixed urogenital flora (common bacteria). R33's Patient Visit Information documents, R33 was prescribed an antibiotic every 12 hours for 3 days for an acute UTI. R33's Medication Administration Record (MAR) dated August 2023 documents, R33 received this antibiotic. On 8/31/2023 at 1:00 PM, V23, Regional Nurse stated, It was normal flora so they wouldn't have prescribed an antibiotic. On 8/31/2023 at 1:10 AM, V2, Director of Nursing (DON) stated, We had already did a urine on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-23 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    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, observation, and record review, the facility failed to provide a meal to residents which is palatable and at an appetizing temperature for 3 of 4 residents (R1, R5, R8) reviewed for food palatability in the sample of 9. Findings include: 1. R1's admission Record, undated, documents, R1 was admitted to the facility on [DATE]. R1's Electronic Medical Record, documents, R1's diagnosis include: Major Depressive Disorder, Osteoarthritis, Congested Heart Failure, (CHF), Type 2 Diabetes Mellitus, (DM), and Hypokalemia. R1's Care Plan, dated 7/14/23, documents, R1 is at increased risk for nutritional issues. Interventions: Provide diet as ordered, obtain weights as ordered, monitor nutritional status, assist with meals as needed, offer supplements/snacks as recommended, obtain/update food preferences. R1's Minimum Data Set, (MDS), dated [DATE], documents, R1 is cognitively and is independent with his Activities of Daily Living, (ADLs). On 8/22/23 at 11:27 AM, R1 stated, I have never had hot food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$32,523 in federal fines across 2 penalties.

  • $22,165 — penalty dated 2025-06-26
  • $10,358 — penalty dated 2025-06-06

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 / managerTypeRoleSince
Ownership Data Not Available

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

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.

$6.6M
Net patient revenuemost recent cost report
-19.3%
Operating marginrevenue minus expenses
$840K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 6%Other / private 20%

About 74% 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 $840K paid to related parties — landlords or management companies under common ownership — equal to about 11% 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

$300per resident / day
operating cost
$9,105per month
≈ monthly operating cost
$251per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146075. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-19, 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.

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