Integrity Hc Of Herrin
1900 North Park Avenue, Herrin, IL 62948 · For profit - Corporation · 49 certified beds · (618) 942-2525 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)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (73%) runs well above the national median (45%)
- 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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 35.8% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 6.3% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 6.6% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.1% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 2.4% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.2% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 32.8% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 33.3% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.8% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.6% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.5% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 35.7% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 22.0% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.7% | 13.9% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
48.0% 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 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 48.0%CMS range 29.8–74.2 | 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 | 10.6%CMS range 7.0–16.5 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.01 | 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 49 beds and averages 40.5 residents a day — about 83% occupied, or roughly 8 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.04 hrs/resident/day on weekends vs 3.68 on weekdays — 18% thinner on weekends. RN hours go from 0.39 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 73% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.
- Actual harm · G2024-09-23 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 serve an appropriate non-emergent involuntary discharge and allow the resident and resident's family time to appeal the notice for 1 of 1 resident (R185) reviewed for discharge in the sample of 32. This failure resulted in R185 being removed from her environment and suffering psychosocial harm that any reasonable person would after being placed over two hours away from her family and friends without notice. The findings include: R185's Face sheet, dated 09/19/24, documents R185 was admitted to the facility on [DATE] and discharged on 06/18/24 with diagnoses including cerebral infraction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia severe with other behavioral disturbances, vascular dementia unspecified severity with other behavioral disturbances, anxiety, schizoaffective disorder, wandering in diseases classified elsewhere, bipolar II disorder, major depressive disorder recurrent, and cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assist a resident with incontinence care in a timely manner to promote dignity for 1 of 10 residents (R1) reviewed for dignity in a sample of 10. Findings include:R1's admission Record documents an admission date of 2/15/22 with diagnoses including in part: paranoid schizophrenia, post traumatic seizures, insomnia, anxiety disorder, essential tremor, and personal history of traumatic brain injury.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is rarely/never understood. The same MDS documents R1 is dependent with toileting hygiene, the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. R1's current Care Plan documents R1 is at risk for impaired skin integrity related to impaired cognition and R1 is known to refuse incontinence care at times. On 9/11/25 at 8:15 AM, R1 was sitting on the couch in the dining room watching the television. On 9/11/25 at 8:43 AM, R1 was sitting on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-06-25 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 39 residents who currently reside at the facility. Findings Include: The facility Daily Census dated 6/23/25 documents there are 39 residents currently residing at the facility. 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide pericare after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also includes the Focus Area of (R1) has an ADL Self Care Performance Deficit r/t (related to) impaired mobility.…
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 before2025-06-25 · 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 Based on interview and record review the facility failed to ensure call lights were answered timely for 6 of 8 (R1, R4-R8) residents reviewed for call lights in the sample of 18. Findings Include: 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post-traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's MDS (Minimum Data Set) dated 4/4/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toileting hygiene and requires substantial/maximal assistance for bathing. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide peri care after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also…
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 before2025-06-25 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 timely assistance with activities of daily living (ADL's) for 8 of 8 (R1-R8) reviewed for ADLs in the sample of 18. Findings Include: 1.R1's facility admission Record with a print date of 6/24/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include diabetes, malaise, obesity, major depressive disorder, post-traumatic stress disorder, asthma, chronic pain syndrome, rheumatoid arthritis, and reduced mobility. R1's current Care Plan documents a Focus area of (R1) has bowel incontinence. Date Initiated: 4/12/2025. This Focus area includes the Intervention of, .Provide pericare after each incontinent episode. Date Initiated: 04/12/2025. R1's Care Plan also includes the Focus Area of (R1) has an ADL Self Care Performance Deficit r/t (related to) impaired mobility. Date Initiated: 04/12/2025 . This Focus area includes the intervention of .Encourage (R1) to use bell to call for assistance. Date Initiated:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-05-01 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 an effective bed bug control program to ensure the facility was free of bed bugs. This has the potential to affect all 36 residents residing in the facility. The findings included: The facility Midnight Census Report dated 4/30/2025 documented 36 residents living in the facility. On 4/30/2025 at 9:00 AM, R2 stated, she had been the first person to find a bed bug in her room around 3/19/2025. R2 stated, that she seen the bug on the floor by her bed and she smashed it with her foot. R2 stated, she did notify a staff member but is unable to remember whom, but they did take the bug for evidence. R2's Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) of 15 which indicated she is cognitively intact. On 4/30/2025 at 8:10 AM, V3 (Housekeeping/Laundry Supervisor) stated, there had been a bug found in R2's room located on the B-Hall on 3/19/2025. V3 stated, the pest control company came in and treated. V3 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 · F2024-09-23 · 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 Based on observation, interview, and record review the facility failed to ensure transmission based precautions were implemented, and failed to ensure hand hygiene was performed per current standards of practice for 2 of 6 (R85 and R3) residents reviewed for infection control in the sample of 32. Findings Include: R85's admission Record with a print date of 9/19/24 documents R85 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, Alzheimer's disease, dementia, and bipolar disorder. R85's MDS (Minimum Data Set) dated 7/9/24 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates R85 has a severe cognitive deficit. R85's Order Summary Report dated 9/19/24 documents a physician order with a start date of 9/11/24 of Transmission based precautions until 9/22/2024 R85's current Care Plan documents a Focus area of (R85) has tested positive for Covid 19. Date Initiated: 09/10/2023. Revision on: 09/12/2024. This Focus area includes the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-23 · tag F0919 — failed to provide a working call system — widespreadMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to provide a method to call for assistance while in the shower stall. This has the potential to affect all 32 residents residing at the facility. Findings include: On 09/18/24 at 11:20 AM the shower stall on the B hall does not contain a method to call for assistance from the shower stall, there is no access to a call light. On 09/18/24 at 11:30 AM the shower stall on the A hall does not contain a method to call for assistance from the shower stall, there is no access to a call light. On 09/19/24 at 12:02 PM V1 (Administrator) stated, the shower stalls should have a method to call for assistance that can be accessed from the floor if someone was in there, so another call box in the shower stall or a way to make the other call box string accessible from the shower. On 09/19/24 at 2:30 PM V1 stated, they do not have a policy regarding call light presence. The long term care facility application for Medicare and Medicaid dated 09/16/24 documents a census of 32 residents residing at the facility.
- Potential for harm · Ecited before2024-09-23 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to provide a dignified and respectful dining experience by removing plates from the table while other residents are still eating for 4 (R30, R27, R16 and R18) of 4 residents reviewed for dignified dining. Findings include: On 09/18/24 at 12:25 PM, V10 (Dietary) was rolling a cart through the dining room with a white bucket (approximately 5 gallon size) on the cart and would pick up residents plates, scrape the leftover food into the bucket and stack the plates on the cart and place the silverware into another bucket. At the first table, R30 was finished while three residents were still eating. Right after V10 took R30's plate, R27 put her silverware down and rolled away from the table. At 12:27 PM, V10 went to the next table and removed R16's plate and glass, and R16 stated hey, I am not done with that. V10 gave her the glass back. There were three residents still eating at the table. V10 then attempted to take R18's plate and with her hand on the plate asked, are you finished, R18 stated, no, there were two residents still…
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 · E2024-09-23 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide a clean and sanitary bathroom for 14 (R3, R24, R23, R14, R17, R21, R10, R22, R28, R29, R18, R19, R5 and R30) of 14 residents reviewed for environment in a sample of 32. The findings include: On 09/18/24 at 11:20 AM, the shower stall floor of the shower room on the B hall is cracked around the drain with the floor peeling away. There was an uneven cracked floor with large peeling area on the floor with areas of non-smooth peeling spots of over 2 feet by 2 feet, 6 inches by 5 inches, and mold around the bottom between the wall and the floor of the shower stall. There was a 2.5 inch gap between the wall and the floor on the right side of the toilet. In the front of the toilet in the second restroom on the B hall, there was a black accumulation around the bottom with an approximate 2 inch gap with approximately 0.25 inches of water accumulation. There is no restroom or shower room located on the C hall. On 09/18/24 at 11:51 AM, the room labeled men's bathroom on the B hall had an accumulation of dirt and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-23 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent physical abuse of a resident from another resident with a known history of abuse for 1 of 3 residents (R16) reviewed for abuse in the sample of 32. The findings include: The Final IDPH (Illinois Department of Public Health) Incident and/or Abuse Notification, with an incident date of 9/20/23, documents, It was reported by staff that on 9/20/23 (R85) (resident) entered (R16's) (resident) room. (R16) loudly told her to leave her room. (R85) became startled and made contact with (R16). (R16) alerted nearby staff who immediately intervened and separated both residents. Nursing assessed both residents for any injuries. Slight bruising to (R16's) upper lip was noted. Nursing provided first aid to the affected area. (R85) was easily redirected and provided with additional activities. (R16) was provided with comfort and support. No further issues were noted Abuse is substantiated The Final IDPH Incident and/or Abuse Notification, with an incident 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.
Show the remaining 20 citations
- Potential for harm · Dcited before2024-09-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility staff failed to report an allegation of resident to resident physical abuse to the Administrator immediately for 1 of 3 (R16) residents reviewed for abuse and neglect in the sample of 32. The findings include: The Final IDPH Incident and/or Abuse Notification date of incident 9/13/24 documents, An unwitnessed allegation involving a resident to resident altercation was reported by (R16) (resident). An investigation was initiated. It was reported by (R16) that (R85) (resident) made contact with Her (resident) while in the dining room. (R16) stated that both residents separated themselves without any further issues. Nursing assessed both residents for any reddened areas or injuries. None were noted. (R85) is care planned for behaviors with impaired cognitive/thought processes. (R16) is care planned for delusional behavior and anxiety. These behaviors can impair both residents' ability to make good decisions and affects their safety awareness. This is an unwitnessed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-23 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a resident or representative and the Ombudsman with a written notice of discharge with appeal rights for 1 of 1 resident (R185) reviewed for discharge in the sample of 32. The Findings include: R185's Face sheet, dated 09/19/24, documents R185 was admitted to the facility on [DATE] and discharged on 06/18/24 with diagnoses including cerebral infraction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia severe with other behavioral disturbances, vascular dementia unspecified severity with other behavioral disturbances, anxiety, schizoaffective disorder, wandering in diseases classified elsewhere, bipolar II disorder, major depressive disorder recurrent, and cognitive communication deficit. R185's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 00, indicating R185 has severely impaired cognition. Section E documents no hallucinations or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-23 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned 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 provide a discharge summary for 1 of 1 resident (R185) reviewed for discharge in a sample of 32. The findings include: R185's Face Sheet, with a print date of 09/19/24, documents R185 was admitted to the facility on [DATE] and discharged on 06/18/24 with diagnoses including cerebral infraction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia severe with other behavioral disturbances, vascular dementia unspecified severity with other behavioral disturbances, anxiety, schizoaffective disorder, wandering in diseases classified elsewhere, bipolar II disorder, major depressive disorder recurrent, and cognitive communication deficit. R185's Minimum Data Set (MDS) dated [DATE] documents in Section C a Brief Interview for Mental Status (BIMS) score of 00, indicating R185 has severely impaired cognition. Section E documents no hallucinations or delusions, no physical behavioral symptoms directed towards others, 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.
- Potential for harm · Dcited before2024-09-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to follow physician's orders as prescribed for one (R14) of one resident reviewed for respiratory concerns in a sample of 32. The findings include: R14's face sheet documents an admission date of 03/26/2021 with diagnoses including: chronic obstructive pulmonary disease, moderate persistent asthma with (acute) exacerbation, dementia, and anxiety disorder. R14's Nurse's Note dated 09/14/24 at 4:23 PM documents: R14 came up to this nurse and stated, I don't feel well at all. This nurse asked the resident what was wrong, and she stated, I cannot stop coughing and I feel SOB (short of breath). This nurse assessed R14 and R14 has wheezing noted in all lung fields. The resident has some shortness of breath and a nonproductive cough that has been constant. R14 expresses that she is very tired as well. Covid test is negative. Vital signs are as follows: T (temperature) 97.5 (degrees Fahrenheit) P (pulse) 86, R (respirations) 20, BP (blood pressure) 151/82, and O2 (oxygen) 95% on 4L (liters). V15 (Medical Physician)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide supplements as ordered and follow the facility policy for weight management for 2 (R27 and R15) of 4 residents reviewed for nutrition in a sample of 32. Findings include: 1. R27's face sheet documents an admission date of 08/06/24 with diagnoses including: unspecified physeal fracture of lower end of right fibula, dementia, muscle weakness, and chronic kidney disease. R27's Minimum Data Set (MDS) dated [DATE] documents: a Brief Interview for Mental Status of 04, indicating R27 has severe cognitive impairment, section GG documents eating assistance is: supervision or touching assistance. R27's Physician Order Sheet documents a dietary order of: regular diet with mechanical soft texture, and thin liquids with an order date of 08/06/24 and no end date listed. R27's weights are documented as: 8/6/2024 at 2:57 PM: 118.0 Lbs (pounds), 8/8/2024 at 3:56 PM: 118.0 Lbs, 8/22/2024 at 5:45 PM: 100.0 Lbs, 8/23/2024 at 2:14 PM: 99.5 Lbs, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-23 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide diets as ordered for 2 (R18 and R24) of 4 residents reviewed for nutrition in a sample of 32. The findings include: R18's face sheet documents an admission date of 07/05/23 with diagnoses including: dementia and diastolic heart failure. R18's Physician's Order Sheet documents an order for: regular diet with mechanical soft texture, thin liquid consistency, cut meats, super cereal, and snack between meals. Ice cream at lunch and supper. Extra dessert at lunch and supper, health shakes twice daily after breakfast and after lunch with an order date of 07/22/2024 and no end date listed. R18's care plan documents an undated focus area of: R18 is as risk for comprised nutritional status related to Diagnosis of Alzheimer's disease or related dementia. R18 is on a mech (sic) soft regular diet per her request as she has difficulty at times chewing meats with her partial dentures with an undated intervention of regular mech soft diet, cut meats and super cereal, ice cream for lunch and supper. R24's face sheet…
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 before2023-08-07 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 adequate staff to meet the care needs of the residents. This has the potential to affect all 34 residents residing at the facility. Findings Include: The Resident Census and Conditions of Residents dated 7/31/23 documents there are 34 residents residing at the facility. This same form documents 17 residents require assist of one or two staff for bathing and 17 residents are dependent on staff for bathing, 34 residents require assist of one or two staff for dressing, 33 residents require assist of one or two staff and one resident is dependent on staff for transferring, 34 residents require assist of one or two staff for toileting, and 33 residents require assist of one or two staff for eating, with one resident documented as dependent on staff for eating. The Midnight Census reports provided to this surveyor on 8/7/23 by V1 (Administrator) document, three residents (R1, R13, R26) require a mechanical lift to transfer and all 34 residents residing at the facility are incontinent and require assist of staff 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 before2023-08-07 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 an environment free of excessive flies. This has the potential to affect all 34 residents residing in the facility. Findings include: On 7/31/2023, at 10:00 AM, 4 flies were observed in R27's room. On 8/01/2023, at 11:30 AM, 3 flies were observed in R33's room. On 07/31/23 at 9:15 AM, three flies were flying around R31's room periodically trying to land on him with him swatting them away. At that time R31 stated the flies are bad. R31's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 13 indicating cognitively intact. On 07/31/23 at 12:30 PM, R29 had two fly strips in her room, one with 5 dead flies and one with 7 dead flies on it with two more flies flying around the room. At that time R29 stated, there are a lot of flies in here. R29's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) as 07 indicating severely impaired. On 07/31/23 at 12:30 PM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-07 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 food in the form that is ordered by a physician for 7 of 7 residents 7 (R9, R17, R22, R27, R32, R33, and R237) reviewed for mechanical soft diet in a sample of 41. Findings include: 1. The facility document titled, Diet Spreadsheet dated week 2, Day 9 - Monday, documents: Dental Soft (Mech (Mechanical soft) Soft) Lunch: Grnd (Ground) Herb Chicken with Gravy, Creamy Noodles, Chopped Soft [NAME] Beans and Chopped Strawberry Shortcake. The facility document titled, Grnd (Ground) Chicken with Gravy documents: 8. Portion #8 dipper, or adjusted dip size based on test weight, of ground meat on plate. Ladle an additional 1-2 oz (ounces) gravy on top. The facility document titled, Chopped Soft [NAME] Beans documents: Before serving, chop vegetables, as needed, chop vegetable into bit-size pieces (one-half inch or no bigger than 1.5 cm (centimeter) x 1.5 cm (centimeter), which is about the width of a standard dinner fork. One-half inch equals 1.27 cm (centimeter). On 07/31/23 at 12:00 PM as lunch trays were being…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation the facility failed to provide privacy and security of possessions for 3 (R4, R12, & R20) of 3 residents reviewed for resident rights in a sample of 41. The findings include: 1. R20's Profile Sheet documents being admitted to the facility on [DATE] with a diagnosis of hypothyroidism. R20's Minimum Data Set (MDS) dated [DATE], documents Section C, Brief Interview for Mental Status (BIMS) score is 15, indicating that R20 is cognitively intact. On 7/31/2023, at 9:30 a.m., R20 stated that R17 comes into her room often and likes to go through her belongings at times. R20 stated that she keeps a lock on her closet door and fridge to keep R17 from taking her things. At this time, a lock is observed on R20's fridge and closet door. R20 stated she is just tired of her coming into her room unannounced. 3. R4's Profile Sheet documents being admitted to the facility on [DATE] with a diagnosis of Type II Diabetes Mellitus with Hyperglycemia. R4's MDS, dated [DATE], documents in Section C, a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure allegations of abuse were reported to the Administrator/designee immediately for 1 of 1 (R2) residents reviewed for abuse in the sample of 41. Findings Include: R2's admission Record with a print date of 8/7/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include unspecified convulsions, history of traumatic brain injury, muscle weakness, major depressive disorder, mild cognitive impairment, and unspecified mental disorder. R2's MDS (Minimum Data Set) dated 7/3/2023 documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates a severe cognitive impairment. On 8/2/2023 at 8:45 AM, V6 (Certified Nursing Assistant/CNA) stated she worked on 7/28/2023, at night and during that shift, V14 (LPN/Licensed Practical Nurse) reported to V6 she witnessed on 7/24/2023, V15 (CNA) punch R2 twice in the head. V6 stated she reported this incident to V2 (Director of Nursing) on Saturday morning, 7/29/2023. On 8/2/23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 a thorough investigation was completed after an allegation of abuse was reported to the facility for 1 of 1 (R2) resident reviewed for abuse in the sample of 41. Findings Include: R2's admission Record with a print date of 8/7/23 documents R2 was admitted to the facility on [DATE] with diagnoses that include unspecified convulsions, history of traumatic brain injury, muscle weakness, major depressive disorder, mild cognitive impairment, and unspecified mental disorder. R2's MDS (Minimum Data Set) dated 7/3/2023 documents a BIMS (Brief Interview for Mental Status) score of 05, which indicates a severe cognitive impairment. The undated Final IDPH Incident and/or Abuse Notification documents, On 7/29/23 an allegation of abuse was reported by staff involving (R2). Nursing assessed (R2) for any injuries with none noted. An investigation immediately began. (V6) reported to (V2) that (V14) told her that she witnessed (V15) make contact with (R2). V14…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interview and record review the facility failed to ensure residents received incontinence care and showers for 2 of 2 (R36 and R87) residents reviewed for Activities of Daily Living (ADL's) in the sample of 41. Findings Include: 1. R87's admission Record dated 8/1/23 documents R87 was admitted to the facility on [DATE] with diagnoses that include traumatic hemorrhage of cerebrum, disorientation, sepsis, nontraumatic subarachnoid hemorrhage, heart failure, hypertension, and hypothyroidism. R87's MDS (Minimum Data Set) dated 6/11/2023 documents R87 has a BIMS (Brief Interview for Mental Status) score of 00, which indicates R87 has a severe cognitive deficit. R87's MDS documents under Section G, R87 requires extensive assistance of two staff for toileting. R87's undated care plan documents a Focus Area of, (R87) has an ADL Self Care Performance Deficit r/t (related to) Confusion, Impaired balance, Limited Mobility, and falls. This focus area has an initiation date of 6/16/2023. The interventions documented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure wounds were identified, assessed, and treated for 2 of 2 (R36 and R87) residents reviewed for wounds. The facility failed to ensure appointments with a specialist were obtained for 1 of 1 (R25) resident reviewed for infection control in the sample of 41. Findings Include: 1. R87's admission Record with a print date of 8/1/23 documents R87 was admitted to the facility on [DATE] with diagnoses that include traumatic hemorrhage of cerebrum, sepsis, non-traumatic subarachnoid hemorrhage, heart failure, hypothyroidism, hypertension, history of falls, and a cardiac pacemaker. R87's MDS (Minimum Data Set) dated 6/11/23 documents a BIMS (Brief Interview for Mental Status) score of 00, which indicates a severe cognitive deficit. R87's undated Care Plan documents a Focus Area of, (R87) is incontinent of B&B (bowel and bladder) and requires assist with ADL's (Activities of Daily Living). (R87) currently has no pressure wounds. (R87's) skin is fragile. 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 · D2023-08-07 · 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, observation, and record review, the facility failed to provide supervision. This failure led to an elopement of 1 (R17) of 1 resident reviewed for elopement in a sample of 41. The findings include: R17's medical record Profile Sheet documents that R17 was admitted to facility 10/22/2021 with a diagnosis of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified dementia, severe, with other behavioral disturbance. R17's Minimum Data Set (MDS) dated [DATE], documents in Section C, a Brief Interview for Mental Status (BIMS) score of 00, indicating that R17 has severe cognitive impairment. Section G, Functional Status documents that R17 requires extensive assistance with one person physical assist with bed mobility, supervision with two person physical assist with transfers, limited assistance with one person physical assist with ambulation and eating, extensive assistance with two person physical assist with dressing, personal hygiene, and toilet…
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 · F2022-09-09 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to maintain adequate levels of quaternary sanitizer used to sanitize food contact surfaces and stationary equipment. This has the potential to affect all 25 residents living in the facility. The Findings Include: On 9/6/22 at 9:30 AM, during the initial tour of the kitchen it was observed that there was a bucket of sanitizing solution setting in the sink with a rag in it. V3 (Cook) stated that this is a quaternary ammonium solution that is used to wipe down surfaces and stationary equipment. V3 checked the solution for the sanitizer level in the bucket with a hydrion test strip to detect quaternary levels. V3 stated the level was below manufacturer suggested level of 200 PPM (parts per million) likely due to being setting out for a few hours. V3 stated at this time she would dump out this bucket of solution and make a new one. On 9/7/22 at 11:15 AM, V3 checked the sanitizer level in the bucket used for sanitizing stationary surfaces and again it was found to be below suggested the manufacturer recommendations 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.
- Potential for harm · D2022-09-09 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 of 8 residents (R22) reviewed for comprehensive assessments in a sample of 29. Findings include: R22's admission Record documented, admission date of 7/30/2022 and initial admission date of 10/8/2022. Diagnosis included, Pressure ulcer of right elbow, stage 4 effective and Pressure Ulcer of sacral region, stage 4. R22's Minimum Data Set (MDS) dated on 7/18/2022 documented in part, section c. Brief Interview for Mental Status (BIMS) a score of 00 which indicates severe cognitive impairment. The Section G. for Functional Activities of Daily Living (ADL) assessment documented resident required extensive assistance of 2 staff for bed mobility, transferring, and toileting. On Section M. skin assessment resident was at risk for pressure ulcer development and no pressure ulcers or other skin issues were present. R22's Initial Skin Alteration Record dated on 7/18/2022 documented in part, wound to right elbow measuring 2 x 2 centimeter non blanchable ulcer with some slough…
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 · Bcited before2024-09-23 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 the required 80 square feet of floor space per resident for 8 of 8 (R6, R7, R14, R15, R17, R22, R28, and R32) residents reviewed for room size in the sample of 32. Findings include: On 09/19/24 at 7:23AM V1 (Administrator) accompanied by this surveyor measured R15 and R32's room with a measuring tape, the room measured 147 inches by 150 inches which equals 153.13 sq. square (sq) feet, which indicates 76.56 sq feet per person the room contained: 2 bed, 2 nightstands, 2 bedside tables, 1 oxygen concentrator, 2 wheelchairs, 1 portable oxygen tank, and a cabinet. On 09/19/24 at 7:24AM R15 who was alert to person, place, and time, stated he had no concerns with his room size. On 09/19/24 at 7:30AM V1 accompanied by this surveyor measured R17 and R14's room with a measuring tape, the room measured 142 inches x 150 inches which equals 145.83 square (sq) feet, which indicated 72.92 sq feet per person the room contained: 2 beds, 1 chair, 2…
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 · Ccited before2023-08-07 · tag F0912 — widespreadProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
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 the required 80 square feet of floor space per resident for 34 (R1-R10, R12-R27, R29-R33, R89, R137, and R237) of 34 residents reviewed for room size in the sample of 41. Findings Include: On 8/1/23 beginning at 2:27 PM, V24 (Maintenance Director) accompanied by this surveyor measured all the resident rooms that didn't meet the required 80 square foot of floor space per resident. The measurements were as follows: Rooms 6, 7, 8, 18, and 19 measured at 140 (inches) x 150 which equals 145.83 square (sq) feet, which indicates 72.92 sq feet per person. Rooms 3, 4, 5, 9, 11, 14-17, 20, 21, 24, and 25 measured at 142 x 150 which equals 147.92 sq feet, which indicates 73.96 sq feet per person. rooms [ROOM NUMBER] measured at 145 x 151 which equals 152.05 sq feet, which indicates 76.02 sq feet per person. room [ROOM NUMBER] measured at 147 x 150 which equals 153.13 sq feet, which indicates 76.56 sq feet per person. This surveyor 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.
- No harm found · Ccited before2022-09-09 · tag F0912 — widespreadProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview the facility failed to provide 80 square feet of space per resident for 25 of 25 residents (R1-R2, R4-R9, R11-R26, and R127) reviewed for room size in the sample of 29. The Findings Include: On 09/8/22 at 12:14 PM, V1 (Administrator) stated all rooms on A, B, and C Hall are covered under the room waiver. All of the rooms have been measured and do not provide the required 80 square feet per resident bed. V1 also stated at this time that the A Hall (rooms 1-12) are Medicaid Certified only and B and C Hall are dually certified for Medicare and Medicaid. These rooms (1-12, 14-26) were all double occupancy rooms measuring 73.4 square feet. Inquiries regarding these rooms throughout the survey from 09/6/2022 to 09/9/2022 found no negative interviews from residents or families of residents who reside in these rooms. Observations of the rooms found there was adequate space to meet the medical and personal needs of the residents living in the waiver rooms. Incident and Accident Records were reviewed for January 2022 to September 2022 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to INTEGRITY HEALTHCARE COMMUNITIES — 5 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.0 | ≈ chain avg |
| Health inspection | 3 of 5 | 2.2 | +0.8 vs chain |
| Staffing | 1 of 5 | 1.2 | -0.2 vs chain |
| Quality measures | 2 of 5 | 2.4 | -0.4 vs chain |
The other 4 homes this chain runs (chain average 2.0★, per CMS)
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
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HANSON, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2024 |
| IRNI, ALAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2010 |
| KELLEY, KELLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/14/2013 |
| SHURTZ, ELIZABETH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/09/2026 |
| BLISKO, STEVEN | Individual | ADP OF THE SNF | since 01/01/2021 |
CMS files one row per role, so the 9 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — 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.
About 92% 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 $500K paid to related parties — landlords or management companies under common ownership — equal to about 14% 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 146092. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-23, 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.