Evercare of Calhoun
#1 Myrtle Lane, Hardin, IL 62047 · For profit - Limited Liability company · 80 certified beds · (618) 576-2278 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2024
- it has 4 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $25,740 in federal fines (most recent 2024-07-19)
- its payroll-based staffing rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 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 improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.4% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.8% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.7% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.8% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 1.3% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.6% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 18.8% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 44.2% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 4.8% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 23.5% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.4% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.7% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 11.8% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 15.3% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.36 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.14 | 2.22 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
40.8% 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 65 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.7% 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 26 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.8%CMS range 32.1–52.2 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.5–14.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 57.7% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.9–13.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.34 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 80 beds and averages 58.9 residents a day — about 74% occupied, or roughly 21 beds typically open. It usually has some room. 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.80 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 2.52 hrs/resident/day on weekends vs 3.25 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.71 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% 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.
29 citations, most serious first. The 14 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2025-10-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain resident safety for 1 of 4 residents (R2) reviewed for resident safety in the sample of 4. This failure resulted in R2 being left unattended, suffering a fall, and sustaining a hematoma to the left side of R2's head and severe pain to left hip. R2 required a transfer to the local hospital and found to have sustained a subcapital femoral neck fracture with at least 2.2 CM (centimeter) superior and 1.5 CM lateral displacement of the fracture. After family and medical considerations, R2 was then transferred to the Regional Hospital Trauma Service for evaluation of surgery where R2 underwent a Left Hip Hemiarthroplasty. Findings include:R2's admission Record, dated 10/15/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, Dementia, Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Congested Heart Failure (CHF), Anxiety disorder, Major depressive disorder, Convulsions, Lymphedema, Anemia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-07-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement care plan interventions to prevent falls for 1 of 5 residents (R44) reviewed for falls in the sample of 46. R44 sustained multiple falls while at the facility, including a fall that resulted in a fracture of the left hip. Findings include: R44's Face Sheet, printed 7/19/24, documents she has a diagnosis of Other fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing, Encounter for other orthopedic aftercare, and Fracture of unspecified part of neck of left femur, initial encounter for closed fracture. R44's Minimum Data Set (MDS) dated [DATE] documents R44 is severely cognitively impaired and requires supervision and touch assistance for transfers into chair or bed to chair transfers. R44's undated Care Plan with the goal date of 10/24 documents, Safety Notes: I have a history of falling and am a continued fall risk. I have poor safety awareness. Make sure I have nonskid socks or shoes…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-06-05 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to provide pain relief for 1 of 16 residents (R51) reviewed for pain in the sample of 36. This failure caused R51 to holler out and moan in pain and show physical signs of pain from 10:48 AM until 3:10 PM on 5/30/23. Findings include: R51's Face Sheet, print date of 5/31/23, documents that R51 was admitted on [DATE] and has diagnoses of Dementia, Type 2 Diabetes and Urgency of urination. R51's Minimum Data Set, dated [DATE], documents that R51 is severely cognitively impaired. R51's Nursing Note, dated 5/30/23 at 2:41 AM, documents, Resident returned to facility about 2:25 AM per (local hospital) ambulance by 2 EMT's (Emergency Medical Technicians). Resident has a left pubic fx (fracture). New orders for Hydrocodone 5/325 1 or 2 tabs (tablets) PO (by mouth) Q (every) 6 hours PRN (as needed), Zofran 4 mg (milligrams) PO Q 6 hours PRN, No weight bearing and to make an appointment with (V18 Orthopedic Doctor) on 5/30/23 for follow up noted.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-06-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to obtain pain medication in a timely manner and have a system in place to obtain pain medication for a resident in a timely manner for 1 of 16 residents (R51) reviewed for pharmacy services in the sample of 36. This failure caused R51 to holler out and moan in pain and show physical signs of pain from 10:48 AM until 3:10 PM on 5/30/23. Findings include: R51's Face Sheet, print date of 5/31/23, documents that R51 was admitted on [DATE] and has diagnoses of Dementia, Type 2 Diabetes and Urgency of urination. R51's Minimum Data Set (MDS), dated [DATE], documents that R51 is severely cognitively impaired. R51's Nursing Note, dated 5/30/23 at 2:41 AM, documents, Resident returned to facility about 2:25 AM per (local hospital) ambulance by 2 EMT's (Emergency Medical Technicians). Resident has a left pubic fx (fracture). New orders for Hydrocodone 5/325 1 or 2 tabs (tablets) PO (by mouth) Q (every) 6 hours PRN (as needed), Zofran 4 mg (milligrams)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-19 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 involve the resident and resident representative in the development of the discharge plan and inform the resident and representative of the final plan in 1 of 3 residents (R2) reviewed for transfer and discharge in the sample of 3. This failure resulted in a disruption in R2's environment, causing reorientation issues and worsening confusion. This past non-compliance occurred from 7/18/25 to 7/21/25.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and diabetes mellitus.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, ambulated independently, wandered daily, and had both verbal and other behaviors one to three days per week.R2's Care Plan does not address any plan for discharge.R2's 7/6/25 Progress Note by V9, Licensed Practical Nurse (LPN), documents V10 and V7, R2's Family, were looking for a facility for R2 with a locked memory…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-19 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to document notice of transfer requirement for 1 of 3 residents (R2) reviewed for transfer and discharge in the sample of 3. This past non-compliance occurred from 7/18/25 to 7/21/25.Findings include:R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and diabetes mellitus.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, ambulated independently, wandered daily, and had both verbal and other behaviors one to three days per week.R2's Care Plan does not address any plan for discharge.R2's 7/17/25 Progress Note by V11, LPN, documents R2 will be discharging to another facility on 7/18/25.R2's Progress Notes do not document R2's discharge notice was given or family was contacted regarding R2's discharge.On 8/19/25 at 10:39 AM, V7, R2's Family, stated she is R2's Power of Attorney (POA) and was never notified of R2's discharge by the Facility.On 8/19/25 at 1:55…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-19 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review the facility failed to ensure they had a qualified Infection Preventionist responsible for the facility's Infection Control Program at the facility. This has the potential to affect all 57 residents living in the Facility. Findings include: On 7/16/2024 at 9:00AM, V1, Administrator stated, (V3), Registered Nurse (RN)) was the Infection Control Specialist. On 7/19/2024 at 11:00AM, V3, Registered Nurse, RN, stated I took all the modules, but I did not pass the test. I am not taking it again. Facility job description dated 11/1/2019 states Under the direction of the Director of Nursing Services, the Infection Preventionist serves as a support person within the facility, providing guidance and education; assistance in problem solving related to resident care; monitoring compliance with state and federal regulations and coordinates the Infection Prevention and Control Program as set forth in the Resident Care Policy and Procedure Manual. Essential Duties: Maintains certification in Infection Prevention and Control.
- Potential for harm · E2024-07-19 · tag F0600 — failed to protect residents from abuse and neglect — patternProtect 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 ensure residents were free from abuse for 4 of 4 residents (R10, R22, R37, R112) reviewed for abuse in the sample of 45. Findings include: 1. R22's Face Sheet documents R22 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, morbid, obesity and pain. R22's Minimum Data Set (MDS) dated [DATE] documented R22 was severely cognitively impaired and ambulated via wheelchair. R22's Care Plan dated 6/5/24 does not address abuse. R112's Face Sheet documents R112 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, auditory hallucinations, and homicidal ideations. R112 was discharged from the Facility on 12/7/23. R112's MDS dated [DATE] documents R112 was severely cognitively impaired and ambulated with wheelchair and walker. R112's Care Plan dated 9/27/23 does not address abuse. The Facility's Initial Incident Description sent to the Illinois Department of Public Health (IDPH) on 12/6/23 documents,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to investigate and provide treatment for bruises and abrasions to one of three residents (R2) reviewed for resident injury on the sample list of 11. Findings include: R2's Care Plan, not dated, documents, Positioning/Bowel and Bladder/Skin Integrity: Please encourage me to turn and reposition myself when in bed and reposition myself when up in my chair. Assist me if needed. I have a pressure re-distribution mattress on my bed and pressure re-distribution cushion in my wheelchair. Please look at my skin during showers and with any care and report any redness, bruising or open areas to my nurse/MD (Medical Doctor) right away. Please observe my skin weekly and notify MD with any decline or change in condition. R2's Minimum Data Set, undated, documents, that R2 was severely cognitively impaired, required assist from staff for activities of daily living, (ADL), does not document any skin concerns. R2's undated Face Sheet, documents diagnoses including Type 2 diabetes mellitus without complications, Sick sinus syndrome, old…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's family/emergency contact of a change in condition and transfer to the hospital for 1 of 3 residents (R2) reviewed for notification of changes in the sample of 5. Findings include: R2's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses to include adjustment disorder with Mixed Anxiety and Depressed Mood, Hyperlipidemia, Gastro-esophageal Reflux Disease Without Esophagitis, Peripheral Vascular Disease, Nicotine Dependence, Hypothyroidism, Pain and Pneumonia. R2's Face Sheet documents V10 is R2's Responsible Party. R2's Progress Note dated 12/13/23 at 3:25 AM document, 12/12/23 at 7:20 PM EMTs (Emergency Medical Technicians) arrived at the facility after resident called 911 from his cell phone to say he was having chest pain. This nurse accompanied the emergency response team to the resident's room. He told them he called from his cell phone after having chest pain for 2 days. Resident did not report…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-06-05 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to properly store medication, and label Tubersol. This has the potential to affect all 57 residents living in the facility. Findings include: On 5/30/23 at 9:00 AM, The facility's Medication Storage Room was inspected. The refrigerator located in the medication room contained the following: 1. 3 open multidose vial of Tubersol (TB) without an open date. The Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. 2. R33's bottle of liquid Lorazepam Concentrate. 3. R6's bottle of liquid Lorazepam Concentrate. 4. R31's bottle of liquid Lorazepam Concentrate. On 5/30/2023 at 9:05 AM V8, RN, stated that the multidose vial of Tubersol was open and in use. V8 stated that the Tubersol should have an open date on it. V8 stated that the refrigerator should be locked. V8 stated that she unlocked the refrigerator and did not lock it back. On 5/23/2023 at 2:30PM, V2, Director of Nursing, stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 utilize safe transfer techniques to prevent accidents for 4 of 5 residents (R1, R28, R30, R53) reviewed for accidents/supervision in the sample of 36. Findings include: 1. R1's Care Plan, dated 7/26/21, documents I am a total lift for transfers with two staff assist. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 is totally dependent of 2 staff members for transfers. On 5/30/23 at 9:15 AM V11, Restorative Nurse, and V9, Restorative Aide, transferred R1 from her wheelchair to the bed using a full body mechanical lift. V11 operating the controls and V9 stood behind the wheelchair. V9 then moved the machine back and R1 started to sway in the sling. With V9 operating the controls V9 transported R1 from the wheelchair to the bed swinging without staff contact. 2. R28's Care Plan, dated February 3, 2017, documents Since having my stroke, I have left sided hemiplegia. I am not safe to get up on my own. I am a two person assist using…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 complete incontinent and perineal care for 6 of 6 residents (R1, R9, R18, R30, R35 and R53) reviewed for incontinent and perineal care in the sample of 36. Findings include: 1. 05/31/23 10:35 AM R9 was on the bedpan. V9, Certified Nurse Assistant, CNA, removed the bed pan from underneath of R9. V9 rolled R9 back over on to her back. V9 then cleansed R9's abdominal fold, left inner groin and down the center of R9's labia. She did not cleanse R9's right groin. V9 then assisted R9 to roll on to her right side and V9 then cleansed R9's left hip, buttock, and peri rectal area. V9 did not cleanse R9's right hip or buttock. R9's Minimum Data Set (MDS), dated [DATE], documented that her cognition was severely impaired, she was totally dependent upon 2 staff members for toileting and that she was always incontinent of bowel and bladder. 2. R1's Care Plan, dated 7/26/21, documents I am incontinent of both bowel and bladder. I do wear…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-06-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to perform hand hygiene and glove changes appropriately during care, and cleaning soiled bed mattress and wheelchair seat pad for 6 of 6 residents(R9, R18, R33, R35, R48, R50) reviewed for infection control in the sample of 36. Findings include: 1. 05/31/23 10:35 AM, R9 was on the bedpan, V8, Certified Nurse Assistant (CNA) and V9, CNA, came into the room, both performed hand hygiene, both donned gloves. V8, with gloved hands, touched her hair, tucking her hair behind her right ear and the placed hand in shirt pocket, proceeded to the right side of R9's bed to assist with taking her off of the bed pan. V9 proceeded to uncover R9, open the disposable cleansing wipes with same gloved hands, removed the bedpan from underneath R9 and started to cleanse R9's abdominal fold, left inner groin and down the center of R9's labia with the same pair of gloves. V9, with the same soiled gloves, assisted R9 to roll on to her right side and V9 then cleansed R9's left hip, buttock and peri rectal area. 2. On 05/31/2023 at 10:20…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2023-06-05 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to feed residents in a manner which promotes resident's dignity for 1 of 4 residents (R51) reviewed for dignity in a sample of 36. Findings include: On 05/30/2023 during the lunch observation between 12:20 PM to 12:50 PM V3, Registered Nurse Staff Development Coordinator, set up R51's meal tray and stood up and fed R51 the entire meal. On 06/01/2023 at 12:55 PM, V2, Director of Nurses stated that she would expect the staff to be sitting down when feeding a resident. 06/05/2023 at 9:24 AM V2 stated that the facility does not have a policy for staff to be sitting down to feed a resident. R51's Minimum Data Set, dated [DATE], documented that R51 cognition was severely impaired and that she required supervision with physical assistance of 1 staff member.
- Potential for harm · D2023-06-05 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 nutrition was provided as ordered and per standards of practice for 1 of 2 residents (R10) reviewed for tube feeding management in the sample of 36. Findings include: R10's Physician's Order (PO), dated 12/02/19, documents Jevity 1.5 @ (at) 55 ml (milliliters)/hr. (hour) x 24 hours via g tube (gastrostomy tube). R10's Care Plan, dated December 3, 2019, documents I am NPO (Nothing by mouth). I have a diagnosis of Dysphagia. I have a PEG (Percutaneous Endoscopic Gastrostomy)- tube and receive Jevity per MD (medical doctor) orders. I receive Jevity 1.5 at 55ml/hr./24 hours. I have water flushes per tube per MD order. I am to receive medication per tube, all those compatible can be given at once with a 30 ml bolus of water at appropriate times. It also documents that it can be disconnected for no more than one hour a day during ADLs (Activities of Daily Living), therapy, or activities. On 5/30/23 at 9:30 AM R10 was up in wheelchair, out of room. The tube feeding container was not attached to the gastric…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-05-19 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 62 residents in the facility. Findings include: There was no consecutive 8-hour RN coverage in 24 hours on 1/2/22, 1/11/22, 1/15/22, 1/20/22, 1/30/22, 2/7/22, 2/8/22, 3/6/22, 4/20/22, 4/22/22, 4/23/22, 4/29/22, 5/3/22, 5/7/22, 5/8/22, 5/12/22, 5/17/22. On 5/18/2022 at 11:30 AM, the Nursing Working staffing schedule from 1/1/2022 through 5/18/2022 was reviewed with V3, Assistant Director of Nurses. V3 stated that the facility has had some staffing concerns. V3 stated that they are actively recruiting and currently using agency staff to fill shifts. V3 stated that she does not handle the RN schedules and that RN coverage would need to be discussed with V2, Director of Nurses. V3 stated that V2 is out on medical leave at this time and is not available. On 5/19/2022 at 10:27 AM, V2, Administrator, stated that the facility does not have a staffing policy. V2 stated that they follow state and federal guidelines for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-05-19 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to properly store medication, label insulin and discard expired medications. This has the potential to affect all 62 residents living in the facility. Findings include: On 5/17/2022 at 9:15 AM, the North Apple Blossom Street Hall medication cart was inspected. The medication cart contained the following medications: 1. R10's Basaglar 100 unit/ml (milliliter) Kwikpen without open date. V9, Licensed Practical Nurse (LPN). Verified that the medication was open and in use. On 5/17/2022 at 9:17 AM, V9 stated that the Basaglar should have an open date. V9 stated that the the medication should not be used without the open date. V9 stated that there is a specific time that the medication can be used and this is why the open date is important so that the medication is not used past the ?? days. V9 stated that she would destroy the medication. On 5/18/2022 at 2:05PM, V3, Assistant Director of Nursing (ADON), stated that the insulin, tuberculin has a specific use time once open. V3 stated that the open date or the end date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-05-19 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 7. On 5/17/22 at 8:45 AM, V24, agency CNA, was collecting breakfast trays out of residents' rooms without wearing eye protection. On 5/17/22 at 8:48 AM, V24 stated that she was tested for COVID last week but not before her shift today, but she was screened at the front door. 8. On 5/17/22 at 8:50 AM, V11, CNA, was caring for residents on the north hall. V11 wore no eye protection and her K95 mask had one of the straps dangling in front of her neck not around her head. 9. On 5/17/22 at 11:37 AM, V25, unit aide, was in R163's lunch order with no eye protection on. 10. On 5/17/22 at 1:52 PM, V13, LPN, V15, CNA, and V12, CNA, staff development, all entered R7's room to transfer R7 to bed and perform incontinent care. V15 and V13 both donned gloves without hand hygiene. V26, CNA, entered the room and donned gloves without hand hygiene. R7's pants and incontinent brief were removed. R7's pants were saturated with urine from the seat of the pants to the mid-thigh area. The incontinent brief was saturated with urine.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-05-19 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. On 05/17/22 at 11:49 AM, V29, R11's daughter, stated, I don't think they should be locked down again. She (R11) can't see so those papers they hand out for them to do. They tell me she walks the halls. I tell them it's because she is bored and there is nothing for them to do. She is vaccinated and boosted. On 5/17/22 at 2:15 PM, V32 stated, We are doing room activities. I went around today and did resident education. They can read the education and do the games on the back. I don't know how much (R11) got out of it though with her dementia. With the coffee club, I hand out a paper with quotes and quizzes on it. We also have the ability to stream movies into the residents' rooms. We do one in the morning and one in the evening. Unfortunately, the system broke last week so that is not working. Tomorrow we will do coffee club in the morning and at 2:00 PM we will do bingo. They come to the doorway and play. I call all the numbers over the telephone system. We will have 6 games of bingo 5 regular games and one…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-19 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to individualize and address the current needs of residents on the Care Plan for 5 of 16 residents (R7, R31, R37, R41, R61) reviewed for Care Plans in the sample of 33. Findings include: 1. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's Medication Record, dated May 2022, documents, Bactrim DS 1 tab (tablet) po (by mouth) bid (two times a day) x 10 days. Start date of 5/9/22. R7's Treatment Record, dated May 2022, documents, Cleanse wound to left lateral foot with WC (wound cleanser), apply Melgisorb AG and cover dressing daily and prn (as needed) until resolved. R7's Initial Weekly Wound document, dated 5/18/22, documents that R7 has an unstageable pressure ulcer on her left lateral foot measuring 1.0 x 0.7 x 0.2 cm (centimeters). This wound document also documents, Notes: 3/30 resident was noted to have blood filled blister with purple…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-19 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 to promote psychosocial well-being for 8 of 8 residents (R9, R11, R13, R18, R27, R37, R39, and R61) reviewed for activities, in a sample of 33. Findings include: 1. On 05/16/2022 from 9:51 AM until 12:00 PM, R18 was sitting up at nurse's station, playing with a paper facemask that was not on her face. R18 was not involved with any activities. On 05/17/2022 at 9:00 AM, R18 was sitting up across from the nurse's station and was not involved with an activity. At 12:30 PM, R18 remained sitting up across from the nurse's station in her wheelchair not engaged in any activities. On 05/18/22 at 10:30 AM, R18 was sitting up in her wheelchair, in the doorway of her room drinking a cup of coffee. On 05/18/2022 at 2:15 PM, R18 was lying in bed while an activity of hallway bingo was occurring. R18's Care Plan, dated 3/26/2022, documents Please remind me when activities are so I can decide to participate or not. 2. On 05/18/2022 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 implement fall interventions and provide safe transfers for 5 of 6 residents (R3, R7, R31, R37 and R48) reviewed for accidents/surpervision in the sample of 33. Findings include: 1. On 05/18/2022 at 09:47 AM R37 was in bed asleep and there was no bed alarm in place. On 05/18/2022 at 10:40 AM, V20, Certified Nurse's Aide, CNA, stated that R37 should have a bed alarm while he is in bed. R37's Incident report, dated 05/7/2022, documents, (R37's) visitors put him in bed and left the room leaving the bed in an up position, resident then rolled out of bed and received a new skin tear to his right elbow. He denied hurting anywhere. R37's Care Plan dated 5/7/2022, documents, I had a fall on this day, please educate my family of low bed protocol and proper bed positioning for safety. It continues, I have alarms to my bed and wheelchair for safety awareness. R37's Incident report dated 5/12/2022 at 3:31 AM, documented Staff heard resident yelling…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-05-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 7 residents (R7, R48, R51, R54) reviewed for incontinent care in the sample of 33. Findings include: 1. On 5/16/22 at 1:15 PM, V7, Certified Nursing Assistant (CNA) and V8, CNA, transferred R48 from her geriatric chair to her bed via full body mechanical lift. R48's pants were removed and R48 was turned to her side. V7 pulled some wipes out of the package and put them on her bed. V7 reached between R48's legs from behind and wiped from the vaginal area to anal area. Using the same gloves used to clean R48, V7 put some moisture barrier cream on the clean incontinence brief and spread it all over the clean incontinence brief with his hands. V7 then used same gloves to put on a new incontinence brief. R48 rolled over to her back and her vagina and both groins were wiped. R48 was not dried prior to putting on a new brief. V7 stated I got the new depends wet with the wipes, so now we need…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation and record review, the facility failed to provide respiratory care, including the changing of the humidified bottle and the dating and timing of both the humidified bottle and nasal cannula for 4 of 4 residents (R8, R23, R41, R46) reviewed for respiratory care in the sample of 33. Findings include: 1. On 5/16/22 at 11:05 AM, R8 had Oxygen being administered at 2 liters per nasal cannula. The humidified water bottle was empty and was dated 5/1/22. The nasal cannula was not dated. R8's Physician Order dated 3/10/21, documents O2 (Oxygen) at 2 Liters per Nasal Cannula continuous. R8's Care Plan dated 5/16/22, documents (R8) has a diagnosis of Diabetes Mellitus, Alzheimer's, Dementia, COPD (chronic obstructive pulmonary disease), Heart Failure, Depression and Anxiety that (R8) takes medications for. (R8) has accuchecks twice daily with routine insulin per physician order. (R8) also wears Oxygen per nasal cannula continuously. 2. On 5/16/22 at 9:50 AM, R41 was sitting in his wheelchair with Oxygen being administered at one and a half liters per nasal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-19 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 evaluate and assess the use of side rails in a timely manner and explain the risk versus benefits of the use of side rails for 5 of 6 residents (R7, R31, R37, R54, R61) reviewed for side rails in the sample of 33. Findings include: 1. R7's Face Sheet, dated 4/13/22, documents R7 was admitted on [DATE] with diagnoses of Urinary Tract Infection and Dementia with behavioral disturbance. R7's Minimum Data Set (MDS), dated [DATE], documents that R7 is moderately cognitively impaired, requires extensive assistance of 2 staff members for bed mobility and toileting, totally dependent on 2 staff members for transfers. R7's Side Rail Evaluation, dated 5/18/22, documents that R7 had a side rail evaluation done 8/13/21 and then 5/18/22 both of these documents list the only risk of having a side rail physical contact. On 5/18/22 at 1:48 PM, R7 was observed in bed with bilateral half rails raised in up position. 2. R31's Face Sheet, dated 4/14/22,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to monitor and assess a new pressure ulcer and provide the Physician Ordered treatment for existing pressure ulcers for 3 of 7 residents (R6, R31, R37) reviewed for pressures ulcers in the sample of 33. Findings include: 1. R6's Face Sheet, print date of 5/19/22, documents R6 was admitted [DATE] and he has diagnoses of pressure ulcer to heel and type 2 diabetes mellitus. R6's Minimum Data Set (MDS), dated [DATE], documents R6 is cognitively intact and requires extensive assistance from 1 staff member for bed mobility and transfers. R6's Physician Orders, dated 4/13/22, documents, Cleanse right heel ulcer with w/c (wound cleanser) ns (normal saline) apply Santyl and cover dressing daily and prn (as needed). R6's Weekly Wound document, dated 5/13/22, documents that R6 has a right heel pressure ulcer measuring 0.5 x 0.5 cm (centimeters). This Wound documents, Support and Specialty Devices: Heel Boots, Repositioning, Heels Elevated off the bed.…
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.
- No harm found · C2024-07-19 · tag F0868 — widespreadHave 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 implement a Quality Assurance Performance Improvement (QAPI) Program which meets at least quarterly with the required members, including the Medical Director. This failure has the potential to affect all 57 residents who reside in the facility. Findings include: On 7/17/24 at 2:41 PM, V1, Administrator, stated the last QAPI Meeting was in March 2024, and the next meeting has not yet been scheduled. He stated V15, Medical Director, does not regularly attend the meetings, so he sends him a recapulation email after each meeting. On 7/19/24 at 11:25 AM, V1, Administrator, stated a QAPI meeting is set for 7/26/24 with V15, Medical Director, and they will continue on a monthly basis moving forward. He stated he expects all facility policies to be followed. The Facility's Quality Improvement Program revised 10/2022 documents, The Quality Improvement Committee will assess and monitor the quality of services provided to the residents in the facility in order to identify potential problems and/or opportunities for improvement. 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.
- No harm found · C2022-05-19 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
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 Certified Nursing Aides (CNAs) received twelve hours of mandatory in-service training annually. This has the potential to affect all 62 residents living in the facility. Findings include: 1. On 5/18/2022, the facility provided a list of Certified Nurse's Assistants (CNAs) with hire dates. A review of the facility's CNAs annual training was conducted. The review of four CNA training transcripts revealed 4 of the 4 CNAs selected for review did not meet the required 12 hours of required training. V20, CNA, had a hire date of 4/21/2017. According to V20's employee file, the facility has no documentation of the required hours of in-service education training V20 has completed in the last year. On 5/18/2022 at 10:12 AM V20, CNA, stated that she has not had dementia or Alzheimer's training. V20 stated that the facility has not provided dementia or Alzheimer's training to her. 2. V18, CNA, had a hire date of 1/03/01. According to V18's employee file, the facility has no documentation of the required hours 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$25,740 in federal fines across 1 penalty.
- $25,740 — penalty dated 2024-07-19
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| 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.
This home reported $738K 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145910. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-07-19, 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.