Heather Health Care Center

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.04 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 70% of this home’s weekday level — it runs therapy at close to weekday levels right through 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.

Staffing

How full it usually is: this home is certified for 173 beds and averages 152.1 residents a day — about 88% occupied, or roughly 21 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 2.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.45 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.39 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 2.12 hrs/resident/day on weekends vs 2.46 on weekdays — 14% thinner on weekends. RN hours go from 0.50 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 35% is below the national median of 45%.

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

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

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

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

36 citations, most serious first. The 20 most serious are shown; the remaining 16 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-03-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision and maintain a safe environment for one resident that had a diagnosis of schizophrenia, anxiety, and depression, with a documented history of self-harming behaviors and exit-seeking behavior. The facility failed to prevent the resident from accessing a fire extinguisher, which was used to break a second-floor window and exit the building without staff knowledge. This affected one of three residents (R162) reviewed for supervision. As a result, R162 exited through the second-floor window, landed face down outside the facility, and sustained a left leg [NAME] fracture, a severe fracture involving the distal tibia. Findings include:The Immediate Jeopardy began on 01/06/2026 when R162 broke a window in the dining room with a fire extinguisher and jumped out of a second story window (fifteen feet) without facility staff knowledge. R162 landed face down sustaining a [NAME] fracture. V1(Administrator) and V2 (Director of Nursing)…

  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
• Immediate jeopardy · Jcited before2024-04-18 · 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 observations, interviews, and record review the facility failed to protect a cognitively and visually impaired resident's (R1) right to be free from physical abuse from another resident (R2) with known history of aggressive behavior for 1 (R1) of 3 residents reviewed for abuse in a sample of 10. This failure resulted in R1 being physically assaulted by R2. The Immediate Jeopardy began on [DATE] at 04:10 AM when R2 physically assaulted R1 which resulted in R1's emergent hospitalization. V1 (Administrator) was notified on [DATE] at 11:14 AM of the Immediate Jeopardy. The facility presented an acceptable removal plan, and the immediacy was removed on [DATE]. The surveyor conducted onsite investigation on [DATE] to confirm the removal plan was implemented. Findings include: 1. R1 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus; Peripheral Vascular Disease; Schizophrenia; Hypertension; and Presbyopia. According to R1's MDS…

  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
• Immediate jeopardy · Jcited before2024-04-18 · 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, interviews and record reviews, the facility failed to provide adequate supervision and monitoring on a resident assessed to be at risk for elopement due to history of elopement from previous nursing home; failed to ensure the resident did not leave facility without staff knowledge or supervision; and failed to follow elopement policy on procedures and reporting. These failures affected one (R5) of three residents in a sample of 10 reviewed for elopement risk and supervision. These failures resulted in R5 able to eloped from facility. R5 experienced harm by walking to emergency room without shoes on and having to cross a high-volume traffic intersection at night, while allegedly experiencing chest pain. The Immediate Jeopardy began on 04/06/24 when R5 left facility unnoticed and unsupervised, walked without shoes on to local hospital while crossing a high volume traffic intersection at night while allegedly experiencing chest pain. V1 (Administrator) was notified of the Immediate Jeopardy 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-04-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow policy procedures, failed to transcribe physician's orders, failed to follow physician orders, failed to notify the wound care director of resident's skin integrity impairment, failed to ensure that staff were aware of required LALM (Low Air Loss Mattress) settings, failed to ensure that the LALM was on the right setting (while in use), failed to ensure that the LALM was on (while in use), failed to implement preventive interventions, and/or failed to ensure that treatments were administered for two of three residents (R1, R2) reviewed for pressure ulcers. These failures resulted in R2 developing the following (facility acquired) pressure ulcers: sacrum (stage 3), right heel (stage 3), left heel (stage 3), right buttock (stage 2), and left elbow (unstageable). R2's left elbow and left heel developed necrosis. Findings include: 1.) R2 was admitted to the facility on [DATE].R2's diagnoses which include dementia, transient ischemic…

  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 · G2026-04-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to follow policy procedures, failed to document meal intake, failed to provide meal within reach, and/or failed to provide required feeding assistance for two of three dependent residents (R1, R2) reviewed for nutrition. These failures resulted in R2's significant weight loss (-15.6% within 1 month) and R1's significant weight loss (-7.9% within 1 month).Findings include:1.) R2's diagnoses include obesity, dementia, transient ischemic attack and cerebral infarction.R2's (3/3/26) functional assessment affirms substantial/maximal assistance is required for eating.R2's (9/29/22) care plan states resident has an ADL (Activities of Daily Living) self-care performance deficit related to dementia, impaired cognition, incomplete performances, history of stroke, and poor oral intake. Dependent on staff for care, interventions: assist with ADL tasks as needed. The resident requires nutritional support secondary to weight loss, poor oral intake, and dementia. Total assistance is needed with meals, interventions: Set up…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to utilize a gait belt during a transfer for a resident (R2) that requires substantial/maximum assistance for one out of three residents reviewed for falls in a total sample of three. This failure resulted in R2 suffering three fractured ribs after falling to the floor during the transfer. Findings Include: A Nursing note dated 11/13/24 at 1:11PM documents the nurse was notified by the wound care aide that R2 was complaining of exaggerated pain to the right side. R2 stated while being transferred to the wheelchair during the morning get up, balance was lost and subsequently R2 fell to the floor. The nurse was not aware of the incident prior to R2 reporting it. The nurse practitioner was notified and sent R2 out for further evaluation. A Nursing note dated 11/13/24 at 8:41PM documents R2 returned back from the hospital with a diagnosis of closed fracture of multiple ribs. The Hospital Records dated 11/13/24 document R2 came to the hospital with a chief…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-18 · 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 interviews and record reviews, the facility failed to provide necessary care and treatment during change in condition on a resident complaining of chest pain; and failed to monitor escalation of maladaptive behavior for two (R2 and R5) of five residents in the sample of 10 reviewed for quality of care. This deficiency resulted in R2 exhibiting increased wandering and pacing, resulted R2 to commit an assault behavior. This deficiency also resulted in R5 experiencing severe chest pain, eloped from the facility to go to the nearest emergency room for further evaluation and treatment. Findings include: R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Exit Seeking/Wandering/Elopement Risk assessment dated [DATE] documented that…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-04-18 · tag F0697 — failed to manage pain — isolated
  Provide 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 and record reviews, the facility failed to conduct pain assessment and provide necessary care and treatment on a resident complaining of chest pain. This deficiency affect one (R5) of one resident reviewed for pain. This deficiency resulted in R5 experiencing severe chest pain, eloped from the facility without shoes on, to go to the nearest emergency room for further evaluation and treatment. Findings include: R5 is a [AGE] year-old, female, admitted in the facility on 10/20/23 with diagnoses of Schizophrenia, Unspecified; Schizoaffective Disorder, Unspecified; Dementia in other Diseases Classified Elsewhere, Moderate, with Other Behavioral Disturbance; and Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. MDS (Minimum Data Set) dated 04/01/24 documented R5's BIMS (Brief Interview for Mental Status) score of 9 which means moderate impairment in cognition. According to progress notes dated 04/06/24, at around 9:30 PM, V4 (Licensed Practical Nurse, LPN) observed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-03 · 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 follow their Abuse Prevention Policy by not keeping residents free from physical and verbal/mental abused by staff. These failures applied to two (R15, R19) of seven residents reviewed for abuse and resulted in R15 experiencing mental abuse by feeling retaliated against by a staff member and R19 was physically abused by staff hitting R19 with a hanger to the right buttock, leaving a red discoloration. Findings include: R19 is a [AGE] year old male admitted to the facility 7/17/2020 with diagnoses of Alcohol abuse with alcohol-induced anxiety disorder, Unspecified Dementia, Hypertension and dysphagia. According to R19's health record, he is dependent on staff for activities of daily living. On 9/16/23 R19 made an allegation of physical abuse against V4 CNA. Progress note dated 9/16/23 stated, The writer was at the nurse's station and heard a loud popping sound and I traced the sound in the hallway. I then saw the above resident frantically stumbling…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-11-03 · 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 re-evaluate fall care plan interventions for effectiveness after resident falls for residents assessed to be at risk of falling, and failed to have individualized interventions, taking resident cognitive function into account, included in the plan of care to meet specific resident needs to address re-current falls. This failure applied to three (R4, R5, R26) of three residents reviewed for falls and resulted in R4 having multiple falls and sustaining a laceration to the forehead, which required sutures; R5 had a fall which resulted in hospitalization for acute intracranial hemorrhage; and R26 having multiple falls and being observed to wander into other resident rooms unsupervised.The facility failed to keep a resident (R16) free from injury while being provided care by staff and by not implementing effective and personalized fall interventions for a resident (R17) with a history of falls. These failures applied to two (R16, R17) of two…

  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 · F2026-03-13 · tag F0880 — failed to prevent and control infections — widespread
  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 follow facility policy and infection prevention standards of practice by not conducting contact tracing, failing to immediately conduct testing, implement isolation orders and doffing Personal protective equipment prior to exiting an isolation room after two residents (R1 and R11) and one staff member (V8-Certified Nursing Assistant) tested positive for COVID-19 resulting in resident and staff exposure to COVID-19. This failure has the potential to affect a total of 155 residents at the facility. Findings Include:R11 was admitted to the facility on [DATE] with a diagnosis of ataxia, major depressive disorder, type II diabetes, and hypertension.R11's progress notes document on 3/2/26 that R11 sustained a fall and was sent to the hospital. R11 returned to the facility on 3/2/26 with a diagnosis of covid-19.R11's after visit summary dated 3/2/26 documents under diagnosis Covid-19.R11's census documents: 8/26/25 - 3/2/26 R11 room was on unit…

  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 · Ecited before2026-03-13 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to follow its call light policy and ensure call light cords were within reach for 6 residents (R74, R78, R81, R121, R144, and R161) out of 10 residents reviewed for call light accessibility in a sample of 50.Findings include:On 3/3/26 at 10:15 AM, R161 was observed lying in bed. R161's call light cord was observed on the floor next to wall, not within reach.On 3/3/26 at 10:16 AM, 144 was observed lying in bed. R144's call light cord was observed to be twenty inches in length; not within reach.On 3/3/26 at 10:20 AM, R121 was observed lying in bed. R121's call light cord was observed dangling on floor, not within reach.On 3/3/26 at 10:25 AM, R78 was observed lying in bed. R78's call light cord was observed on the floor behind R78's nightstand, not within reach.On 3/3/26 at 10:35 AM, R81 was observed sitting in wheelchair on the left side of R81's bed. R81's call light cord was observed dangling through R81's bedframe at the head-of-bed on the right side of the bed, not within reach.On 3/3/26 at 10:38 AM, R74 was…

  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 · E2026-03-13 · 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 at least every two hours for four residents (R10, R98, R115, and R145) dependent or require maximum assistance of staff for incontinence care out of four residents reviewed for ADLs (Activities of Daily Living) in a sample of 50. Findings include: On 3/3/26 at 10:18 AM, R115 was observed ambulating in the halls. R115's sweatpants was observed to be wet in the buttocks, groin, and upper thighs.R115's MDS (Minimum Data Set), dated 12/8/25, notes R115 is dependent on staff for toileting. R115's BIMS (Brief Interview of Mental Status) score is 5 out of 15, severe cognitive impairment.On 3/5/26 continuous observations were made from 10:10 AM until 1:57 PM on the third unit for R10, R98, R115, and R145. R10 was observed sitting in reclining chair in the resident common area. R98 was observed sitting in wheelchair in dining room. R145 was observed sitting in wheelchair in the dining room.On 3/5/26 during continuous…

  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 · D2026-03-13 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  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 follow its advance directives policy and ensure one resident's (R2) wishes for advance directives are documented in the physician orders of three reviewed for advance directives in a sample of 50.Findings include:On 3/6/26 at 10:45 AM, V32 (Social Services) stated that residents are asked upon admission regarding advance directives. V32 stated that if a resident was admitted with a POLST (physician orders for life sustaining treatment) it would be documented on social services initial assessment and uploaded into the resident's electronic medical record. V32 stated that social services would only notify nursing if there was a change to a resident's code status.On 3/6/26 at 12:30 PM, V2 (Director of Nursing) stated that the nurse is expected to ask the resident and/or resident's representative regarding advance directives. V2 stated that this is part of the admission checklist the nurse completes. V2 stated that the nurse is responsible for reviewing…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-13 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to notify the physician of diagnostic test results indicating the need for further evaluation for 1 of 3 residents (R159) reviewed for physician notification. The findings include:R159's face sheet shows diagnosis of type 2 diabetes, hypertension, anemia, acromegaly, personal history of transient ischemic attack and cerebral infraction without residual effects, unspecified osteoarthritis. R159's radiology results report dated 11/13/25 denotes in-part pt (patient) states he fell today on R159's head, pain in head, no bruising. Test procedures X-ray of skull, four views of skull with no prior studies. There is no definite displaced or depressed calvarial fracture by plain film. Nondisplaced fracture not excluded. Head trauma/injury not evaluated by plain film. Intracranial pathology not evaluated by plain film. CT is clearly and strongly recommended. Impressions CT is clearly and strongly recommended. R159's progress notes dated 11/13/25 completed by V17(Registered Nurse/RN) denotes in-part at 9:30pm views of the skull with no…

  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 · D2026-03-13 · tag F0628 — isolated
  Provide 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 follow their against medical advice policy by not notifying the physician and failing to provide medications for one (R128) resident who left the facility against medical advice for two of three residents reviewed for discharge.Findings include:R128 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with foot ulcer, asthma, bipolar, hypertension and asthma. R128's brief interview for mental status score dated 12/11/25 documents 13/15 which indicates cognitively intact.R128's progress notes dated 3/3/26 at 6:30Pm with a created date of 3/4/2026 07:25:52 documents: Resident left against medical advice (AMA). He was educated on the risks and benefits of continued treatment, verbalized understanding, and elected to leave the facility despite medical advice.R128's progress notes does not document any notification to the physician or nurse practitioner related to R128's leave against medical advice.R128's physician order 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-13 · 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

  Based on observation, interview and record review, the facility failed to ensure Enoxaparin Solution Injection Solution Prefilled Syringe. Injection 0.4ml was available for administration as prescribed. This affected one of three residents (R86) reviewed for available medication.Findings Include:R86's brief interview for mental status dated 12/11/25 documents a score of fifteen which indicates cognitively intact. R86's physician order sheet dated 12/19/2024 documents: Enoxaparin Solution Injection Solution Prefilled Syringe. Inject 0.4ml subcutaneously two times a day related to chronic embolism and thrombosis of unspecified deep vein of lower extremity. Medication Administration Record dated 3/1/2026- 3/31/2026 documents: Enoxaparin Solution Injection Solution Prefilled Syringe; Wednesday 3/4/26 at 6am, 4pm and on 3/5/26 at 6am documents the number nine (9). Chart code/Follow up code nine (9) =other see progress notes. Electronic medication progress note dated 3/4/26 at 6:03am documents: medication not available, awaiting supply from the pharmacy as medication is being reordered,…

  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 · D2026-03-13 · tag F0761 — failed to label and store drugs safely — isolated
  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 follow their medication storage policy by having opened, used, undated and unrefrigerated medication on the medication cart for two of three residents (R3 and R5) reviewed for medication storage. Findings Include:On [DATE] at 3:36pm, during medication cart audit with V26 (Nurse), R3's Insulin Glargine Subcutaneous Solution Pen-injector dispensed on [DATE] was opened, used and not dated. V26 said, R3's insulin should have been dated after opening to ensure expired medication is not given. V26 said, insulin is good for twenty-eight to thirty (28-30) days after opening. R5's Insulin Aspart (with Niacinamide) was observed on the medication cart, new and not used or opened. Refrigerate until opened was documented on the pharmacy bag that held R5's insulin. V26 said, all unopened, unused insulin pens should be refrigerated until they are opened/used. V26 said, R5's insulin should have been in the refrigerator.Medication Storage/Labeling/Packing…

  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 · D2026-03-13 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to maintain a clean and homelike environment on one of three 3 units reviewed. On the third locked unit, two lounge chairs located in the television room were observed with multiple old, dried stains on the seat cushions and armrests. Findings Include: On 3/4/26 at 10:09am, two filthy lounge chairs with multiple dried irregular shaped circles in the middle of the seat cushion, discoloration, dirt and other stains covering the chair and arm rest were observed in the resident television room on the third (3rd) unit. V6 (Nurse) said, residents sit in those chairs and watch television. V6 said, those chairs have been dirty for a long time. On 3/4/26 at 10:20m, V3 (Assistant Director of Nursing) said, the lounge chairs have stains on the cushion and arm rest. V3 said, some of the stains on the cushion are consistent with dried urine and the other stains are consistent with spills. V3 said, the red stain may be consistent with a red juice spill. V3 said, she would not sit in either lounge chair due to the multiple stains/spills. 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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-18 · 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

  Based on observations, interviews, and record reviews, this facility failed to follow its abuse policy and keep its residents free from abuse. This failure resulted in two residents (R2 and R3) having in a verbal altercation that escalated to a physical altercation before staff intervention out of three residents reviewed for abuse in a sample of 3. R3, with a history of physical aggression, hit R2 in the left eye with his fist. R2 sustained a laceration, bruising, and swelling to left eye. Findings include: On 4/16/25 at 2:30 PM, R2 was observed to have left eye swollen shut with ecchymosis (bruising), abrasions above and below left eye. On 4/16/25 at 2:30 PM, R2 stated that R3 has always given him problems. R2 stated that he was getting some more juice after lunch on 4/10, and R3 started yelling at him that he can't have more juice. R2 stated that he told R3 he wasn't the boss. R2 stated that he figured R3 wanted more juice so he threw his cupful of juice on R3 with his right hand. R2 stated that R3 then hit him in the left eye. On 4/16/25 at 1:00 PM, R3 stated that on 4/10 he was…

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

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

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

Fines & penalties

$308,658 in federal fines across 4 penalties. 1 Medicare payment denial on record.

• $63,630 — penalty dated 2026-03-13
• $16,546 — penalty dated 2024-12-06
• $146,192 — penalty dated 2024-04-18
• $82,290 — penalty dated 2023-11-03
• Medicare payment denial — starting 2026-04-10 for 5 days

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

Part of a chain

This home belongs to THE ALDEN NETWORK — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 20 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 93% 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 $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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.

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