Highland 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.

41.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 92 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 63.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 66 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 128 beds and averages 84.6 residents a day — about 66% occupied, or roughly 43 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 2.94 hrs/resident/day on weekends vs 3.46 on weekdays — 15% thinner on weekends. RN hours go from 0.57 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

Inspection trend

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

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

Inspection deficiencies

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

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

26 citations, most serious first. The 14 most serious are shown; the remaining 12 are one tap away and print in full.

• Immediate jeopardy · Lcited before2025-09-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespread
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a systematic approach to assess and evaluate a resident's unsafe wandering, record resident specific information, and monitor a resident with known exit seeking behaviors for 1 of 3 residents reviewed for elopement. This failure resulted in R2 eloping out of the facility on an unknown date and getting down a public street before staff were able to catch up with him and again on 8/25/2025 when R2 was seen exiting the facility unsupervised when police officers patrolling the area heard the alarm and found R2 exiting the fire door attempting to leave unsupervised and with no staff anywhere around. R3's room remains adjacent to the fire door exit. This failure has the potential to affect all 11 residents who are at risk for elopement and wandering.The Immediate Jeopardy began on 7/19/2025, when R2 eloped from the facility through the front doors unattended. On 9/3/2025 at 10:00 AM V1, Administrator; V2, Director of Nursing (DON), and V28 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 before2025-12-05 · 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 observation, interview and record review the facility failed to provide incontinence care for 2 of 3 Residents (R8, R9) reviewed for neglect in the sample of 3. This resulted in R8 and R9 both left saturated in urine for hours and using a reasonable person approach resulted in psychosocial harm that a person would feel ashamed, humiliated, hopeless, and neglected being left in their own incontinence of bowel/bladder. Findings include: 1. R9 R9's undated face sheet documents that he was initially admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and anxiety. R9's admission Bowel and Bladder Assessment, dated 11/17/2025, documents that he has occasional incontinence episodes and requires one-person assistance with toileting. R9's Nurse's Note, dated 10/29/2025 at 7:55 PM, documents that the resident arrived from a local hospital via facility transport. He was able to answer questions appropriately, acclimated to the room, and was given a call light. No signs or symptoms of…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-17 · 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 observation, interview and record review, the facility failed to prevent resident to resident sexual abuse for 1 of 1 (R2) resident reviewed for abuse in the sample of 4. This failure resulted in psychosocial harm in that, a reasonable person would react to such a situation with feelings of anxiety, distress, fearfulness and humiliation. This past compliance occurred from 4/14/2025 to 4/15/2025. Prior to the survey date, the facility took the following actions to correct the noncompliance: -R1 (alleged perpetrator) was immediately removed from the dementia unit on 4/14/2025 upon report of the incident and placed on 1:1 supervision by staff to prevent further resident contact and mitigate risk. - R2 (alleged victim) received immediate psychosocial support. Referred for ER evaluation for possible sexual assault. - All residents on the dementia unit assessed for risk of aggressive or inappropriate behaviors. -Increased supervision on dementia unit, especially during communal activities. - All nursing staff…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-06-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assist residents with activities of daily living for dependent residents including oral and hygiene care for 1 of 4 residents (R2) reviewed for Activities of Daily Living (ADLs) for dependent residents in the sample of 24. This failure resulted in psychosocial harm as a normal person would have been embarrassed if they could not maintain good hygiene and be clean and odor free when going out in public. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteomyelitis, Protein Calorie Malnutrition, Non-Traumatic Extradural Hemorrhage, Aphasia, Parkinson's Disease, Stage 3 Pressure Ulcer to the Sacral Area, PVD (Peripheral Vascular Disease), Dysphagia, Seizures, Neurocognitive Disorder with Lewy Bodies, Dystonia, Hypernatremia, MDD (Major Depressive Disorder and HTN (Hypertension). R2's Minimum Data Set, dated [DATE], documents R2 has severe cognitive impairment, is incontinent of bowel /bladder and is dependent with…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure 2 (R8, R9) of 3 residents received adequate and timely incontinence care for ADL dependent residents reviewed for incontinence in the sample of 3.Findings include:1. R9's Undated Face Sheet documents R9 was initially admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and anxiety. R9's admission Bowel and Bladder assessment dated [DATE], documents R9 has occasional incontinence episodes and needs one assist with his toileting needs.R9's Nurse's Note, dated 10/29/2025 at 7:55 PM, documents resident arrived from local hospital via facility transport. Resident able to answer questions appropriately. Resident acclimated to room and given call light. No s/s (side or symptoms) of distress or injury. TV turned on per resident's request. Resident sitting in wheelchair in room, requested dinner tray as resident states he is hungry. No documentation if resident is incontinent of urine. R9's Electronic Medical…

  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 · D2024-12-05 · 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 review the facility failed to provide pain management for one of three residents (R3) reviewed for pain in the sample of 5. This failure resulted in R3 not receiving pain management for a fall with serious injury for 24 hours. This past non-compliance occurred from 11/16 until 11/18/24. Finding Include: R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired, and R3 requires substantial to maximum assistance. R3's MDS dated [DATE] documents R3 is moderately cognitively impaired. R3 needs partial assistance from another person for any activities. R3's Electronic Health Record documents R3 has diagnoses of FX (Fracture) of Unspecified Part of Neck of Left Femur and Traumatic FX. R3's Pain Care Plan 11/13/24 documents R3 has potential for pain related to unstable angina and COPD (Chronic Obstructive Pulmonary Disease) Interventions: anticipate the residents need for pain relief and respond immediately to any complaint of pain. Observe report to nurse any…

  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 · Past Non-Compliance
• Potential for harm · E2024-09-27 · tag F0761 — failed to label and store drugs safely — pattern
  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

  Based on observation, interview, and record review, the Facility failed to properly store and label medications and dispose of expired medications for 4 of 4 residents (R25, R59, R63, R283) reviewed for medication storage and labeling in the sample of 46. Findings include: On 9/26/24 at 9:15 AM, the medication cart on the B Hall was inspected with V12, Registered Nurse (RN). The medication cart contained the following: 1-R63's Humalog Quickpen labeled 8/24 in black marker. V12, RN, stated insulin pens are dated upon opening and are usually thrown out after 30 days. 2-R63's unopened vial of Epogen with packing instructions documenting, Refrigerate. 3-One half of a white circular tab in a medicine cup that was not labeled or dated. V12, RN, stated, That is magnesium for R59. She gets half a tab in the morning and the other half in the afternoon. 4- One opened carton of thickened lemon water labeled 5/20 in black marker. V12, RN, stated that will be thrown away. On 9/26/24 at 9:22 AM, the medication cart on the F hall was inspected with V10, RN. The medication cart contained 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-09-27 · tag F0881 — failed to use antibiotics responsibly — pattern
  Implement a program that monitors antibiotic use.
  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 a system of unnecessary or inappropriate antibiotic use for 4 out of 4 residents (R16, R28, R45, R48) investigated for antibiotic use in a sample of 36. Finding include: 1. R16's EMR (Electronic Medical Records) dated 11/14/23 documents that resident was admitted to the facility. R16's EMR dated 11/14/23 documents diagnose of Chronic Kidney Disease, Stage 4 (Severe), Neuromuscular Dysfunction of Bladder, Unspecified, and END STAGE RENAL DISEASE. R16's Care Plan dated 02/29/24 documents (R16) has end stage renal failure r/t (related to) End stage disease. R16's MDS (Minimum Data Set) dated 08/07/24 documents a BIMS (Brief Interview for Mental Status) score is 14. The MDS documents that the resident requires substantial/maximal assistance with toilet hygiene. The MDS documents that the resident is always incontinent of bladder and bowel. R16's Nursing Note dated 07/20/24 at 5:23 PM documents Wife and resident aware of positive uti and beginning…

  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 · D2024-06-27 · 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 interview and record review, the facility failed to provide timely care/treatment for 1 of 4 residents (R2) reviewed for quality of care in the sample of 24. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteomyelitis, Protein Calorie Malnutrition, Non-Traumatic Extradural Hemorrhage, Aphasia, Parkinson's Disease, Stage 3 Pressure Ulcer to the Sacral Area, PVD (Peripheral Vascular Disease), Dysphagia, Seizures, Neurocognitive Disorder with Lewy Bodies, Dystonia, Hypernatremia, MDD (Major Depressive Disorder and HTN (Hypertension). R2's Minimum Data Set, (MDS), dated [DATE], documents R2 has severe cognitive impairment is dependent upon staff for ADLs (Activities of Daily Living), has coughing with thin liquids, loss of liquids/solids from mouth when eating/drinking, choking/coughing when eating, swallowing medications, and receives 51/% or more of total calories through tube feeding; receives 501cc/day or more of fluids by tube feeding. R2's Care Plan, dated…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-06-27 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide gastrostomy tube care per standards of practice for 1 of 4 residents (R2) reviewed for tube feeding management in the sample of 24. Findings include: R2's Face Sheet, undated, documents R2 has the following diagnoses: Osteomyelitis, Protein Calorie Malnutrition, Non-Traumatic Extradural Hemorrhage, Aphasia, Parkinson's Disease, Stage 3 Pressure Ulcer to the Sacral Area, PVD (Peripheral Vascular Disease), Dysphagia, Seizures, Neurocognitive Disorder with Lewy Bodies, Dystonia, Hypernatremia, MDD (Major Depressive Disorder and HTN (Hypertension). R2's Minimum Data Set, MDS, 6/9/24, documents R2 has severe cognitive impairment is dependent upon staff for ADLs (Activities of Daily Living), has coughing with thin liquids, loss of liquids/solids from mouth when eating/drinking, choking/coughing when eating, swallowing medications, and receives 51/% or more of total calories through tube feeding; receives 501cc/day or more of fluids by tube feeding.…

  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 · D2024-06-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to provide a clean, comfortable, homelike environment for 3 of 7 residents (R4, R5, R6) reviewed for physical environment in the sample of 7. Findings include: 1. On 6/6/24 at 9:40 AM, R4 was lying in bed in her room. She stated that she usually has to ask staff to change her sheets once a week. She stated that her main complaint about the Facility is clutter in the hallway and said, It's like an obstacle course out there. R4's Minimum Data Set (MDS), dated [DATE], documented that R4 was cognitively intact. On 6/6/24 at 10:35 AM, V3, Certified Nursing Assistant (CNA), stated some of the units could use more attention from Housekeeping. On 6/6/24 at 12:17 PM, the shower in the B Hall bathroom smelled strongly of urine. 2. On 6/6/24 at 12:30 PM, R5 was sitting in his wheelchair in his room. He stated, (Odors) are horrible about 90% of the time. It smells like a bathroom. They have put out deodorizers, but they are not very good. He 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-03-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to ensure progressive fall interventions were in place for 1 of 3 residents (R1) reviewed for accidents and hazards in the sample of 6. Findings include: R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including heart failure, type 2 diabetes mellitus, unspecified dementia, restlessness and agitation, and history of falling. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was severely cognitively impaired, ambulated via wheelchair, was dependent with transfer, and required substantial/maximal assistance with toileting, bathing, dressing, oral hygiene and rolling from side to side. R1's Undated Care Plan documents R1 is at risk for falls and injuries related to medications and medical factors, including heart failure, type 2 diabetes mellitus, and history of falling. R1's Fall Risk assessment dated [DATE] documented R1 was at high risk of falls. R1's 5/4/22 Fall Report documents R1 was found sitting…

  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 · D2023-10-25 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to report an allegation of abuse in 2 of 8 residents (R4, R6) reviewed for abuse in the sample of 9. Findings include: On 10/20/23 at 2:00 PM, V1, Administrator, stated she has a soft file on an allegation of sexual abuse involving R4 and R6, but it wasn't reported, because it was investigated and wasn't sexual abuse. On 10/24/23 at 9:05 AM, V1, Administrator, stated she reported the incident involving R4 on Friday October 20th after talking to surveyor about it. V1 stated, she has not completed the investigation or the final report. The facility's abuse investigation, dated 10/20/23, involving R4 and R6 documents, the following information: date of incident: 10/20/23 at 4:00 PM, Alleged sexual abuse involving R4 and R6. Reported to IDPH, (Illinois Department of Public Health), POA, (Power of Attorney), MD, Family and Police on 10/20/23. Interview with R4 dated 10/17/23, R4 stated, he had his hand (R6) and was telling him that he (R6) needed his fingernails cut and cleaned. R4 tried to clean them, but someone else is going to…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-10-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure fall prevention interventions were in place in 1 of 3 residents (R6), reviewed for falls in the sample of 9. Findings include: R6's Minimum Data Set, (MDS), dated [DATE], documents, R6 has moderate cognitive impairment. R6's Care Plan, dated 2/27/19, documents, R6 is at risk for falls with an intervention, dated 8/12/23 for a pull tab alarm when in bed or up in wheelchair. R6's Fall Risk Assessment, dated 5/20/23, documents, R6 is at high risk for falls. R6's Progress Note, dated 8/12/23 at 3:14 AM, documents, the following: Staff entering room to do bed check at 2:40 AM, found resident curled up on floor on right side of bed, blood coming from skin tear to right elbow, unwitnessed fall, neuro checks started, ROM, (Range of Motion), WNL, (Within Normal Limits), no other apparent injuries noted, administration notified, POA, (Power of Attorney), notified, MD notified, risk management report being completed, will continue to monitor…

  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

“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

$35,875 in federal fines across 1 penalty.

• $35,875 — penalty dated 2025-12-05

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 CREST HEALTHCARE CONSULTING — 11 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 11 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.

2 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.

This home reported $841K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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