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Heritage Health-Hoopeston

423 North Dixie Highway, Hoopeston, IL 60942 · Non profit - Corporation · 75 certified beds · (217) 283-8247 Medicare & Medicaid certified

Call the home — (217) 283-8247 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 20261 actual-harm citation
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, 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 (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (2/5)

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
705 E Orange St Apt 208 · (217) 283-9215 · Call to confirm hours
Pharmacy
Shopko0.8 mi
1020 W Chestnut St · (217) 283-4456 · Call to confirm hours
Grocery
1006-1010 W Chestnut St · (217) 283-6683 · Call to confirm hours
Park
(217) 283-5813 · Typically dawn to dusk
Place of worship

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 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased26.6%13.4%15.4%worse
Long-stay residents who lose too much weight5.1%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder1.8%0.9%0.9%worse
Long-stay residents with a urinary tract infection1.5%1.5%2.0%better
Long-stay residents with depressive symptoms3.9%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained4.4%0.1%0.1%worse
Long-stay residents with falls causing major injury5.8%3.1%3.3%worse
Long-stay residents whose ability to walk worsened34.8%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.5%18.3%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers1.0%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control19.9%20.6%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table10.0%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Long-stay hospitalizations per 1,000 resident days1.762.021.67typical
Long-stay outpatient ER visits per 1,000 resident days3.532.221.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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

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

45.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.9%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
0.13U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.07hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.9%CMS range 34.3–57.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 5.8–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 3.2–13.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.631.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.74
RN hours/ resident / day
0.22
LPN hours/ resident / day
2.01
Aide hours/ resident / day
2.97
Total nurse hours/ resident / day
0.40
RN hoursweekends
29.5%
Total nursing turnover
18.2%
RN turnover

How full it usually is: this home is certified for 75 beds and averages 70.5 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.97 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.64 hrs/resident/day on weekends vs 3.11 on weekdays — 15% thinner on weekends. RN hours go from 0.88 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 30% is below the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2026-05-21)
9
at the previous standard inspection (2024-06-05)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2026-04-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement fall interventions to prevent injury for one of three residents (R1) reviewed for falls on the sample list of three. These failures resulted in R1 sustaining a fall which led to a fracture of both the left ulna and left femoral neck. Findings include:The facility's Fall Assessment and Management Policy, revised June 2024, documents the facility will assess each resident's fall risk and implement interventions to decrease the residents' risk of falls and subsequent risk for injury.R1's Medical Diagnosis List, dated April 2026, documents R1's diagnoses including Alzheimer's Disease, Dementia with Agitation, Anxiety, and Chronic Pain.R1's Minimum Data Set, dated [DATE], documents R1 as severely cognitively impaired. R1 is dependent on staff assistance for transfers.R1's Care Plan, dated 7/1/25, documents R1 is at risk for falls related to confusion, and poor safety awareness. An intervention was added on 2/11/25 for staff to assist R1in…

    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 · E2026-05-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    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 sanitarily store respiratory equipment when not in use. This failure affects four residents (R5, R27, R40, and R74) out of five residents reviewed for respiratory care on the sample list of 41.Findings include: 1. On 5/19/26 at 2:17 PM, R27's Continuous Positive Airway Pressure (CPAP) face mask, with the supply tubing connected to the CPAP machine on top of the bureau, was inside the slightly open top drawer of R27's bedside bureau, unprotected from contamination due to other items in the drawer including a second older CPAP machine, 2 old used partially full concentrator humidifier bottles dated 7/9/25 and 7/17/25, and a box of electric shaver head replacements. R27's Medical Diagnoses List dated 5/20/26 documents R27 experiences medical conditions including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Shortness of Breath, Congestive Heart Failure, Anxiety, Hypertension, and Obstructive Sleep Apnea. On 5/20/26 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 allow one (R62) resident to utilize their own Continuous Positive Airway Pressure (C-PAP) machine from their home environment out of one resident reviewed for resident rights in a sample list of 41 residents. Findings include: R62's undated Face Sheet documents R62 was admitted to the facility on [DATE]. R62's Minimum Data Set (MDS) dated [DATE] documents R62 as cognitively intact. R62's Physician Order Sheet (POS) dated May 2026 documents a physician order starting 4/1/2025 to assist R62 with placing R62's Continuous Positive Airway Pressure (CPAP) on at bedtime. Remove in the morning (AM) when awake. Settings minimum pressure 8, maximum pressure 13 and ramp per R62's preference. On 5/19/26 at 10:45 AM R62 stated staff told R62 that R62 cannot use R62's own C-PAP machine from home because 'they have a contract with the C-PAP company'. R62 stated there was nothing wrong with R62's home C-PAP machine and felt more comfortable with it. R62 stated R62 is…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 record review and interview, the facility failed to complete a significant change Minimum Data Set Resident Assessment for a resident with a significant decline in multiple areas of health status. This failure affects one resident (R11) out of one reviewed for activities of daily living on the sample list of 41.Findings include: R11's Minimum Data Set (MDS) Resident Assessment Instrument dated 12/31/25 documents R11 had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating severe cognitive impairment. This same MDS documents R11 required moderate assistance from staff for bed mobility to roll from side to side, to go from lying to sitting position, from sitting to lying position, and from sitting to standing position. This MDS documents R11 required moderate staff assistance to accomplish a transfer from the bed to a chair, and from a chair to the shower. This MDS documents R11 weighed 146 pounds. This MDS documents R11's skin was free of pressure ulcers, and R11 had no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 complete an accurate Minimum Data Set Resident Assessment Instrument to include the use of non-invasive ventilators (CPAP, Continuous Positive Airway Pressure). This failure affects two residents (R27 and R40) out of five residents reviewed for respiratory services on the sample list of 41.Findings include: 1. On 5/19/26 at 2:17 PM, R27's Continuous Positive Airway Pressure (CPAP) face mask, with the supply tubing connected to the machine, was inside the slightly open top drawer of R27's bedside bureau. R27's Physician Order Sheet dated 5/20/26 documents for nursing staff to refill the CPAP machine with distilled water every night shift; CPAP Daily Care: After removing in the am, empty humidifier, rinse and air dry, rinse mask and tubing with tap water, hang to dry every day shift; and Apply CPAP at HS (hour of sleep), remove in am. CPAP pressure: 18 RAMP (setting that gradually increases air pressure as the patient falls asleep). R27's Care Plan initiated 3/11/25 documents R27 utilizes a CPAP related 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-21 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their Antibiotic Stewardship policy for one (R2) resident out of one resident reviewed for Antibiotic Stewardship in a sample list of 41 residents. Findings include:R2's undated Face Sheet documents R2 admitted to the facility on [DATE] and readmitted on [DATE]. R2's Electronic Medical Record (EMR) documents R2's medical diagnoses as history of Urinary Tract Infection (UTI), Low Back Pain, Mixed Incontinence, Cystitis, Urgency of Elimination, Overactive Bladder and Chronic Pain.R2's Physician Order Sheet (POS) dated May 2026 documents a physician order starting 8/4/2025 and ending 8/4/2026 to administer Bactrim 400-80 milligrams (mg) half a tablet every Monday, Wednesday and Friday morning for recurrent Urinary Tract Infection (UTI) for 12 months.R2's Medication Administration Record (MAR) dated May 2026 documents R2 was administered Bactrim 400-60 mg on May 1, 4, 6, 8, 11, 13, 15, 18 and 20.On 5/21/26 at 2:00 PM V3 Infection Preventionist (IP)…

    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 · D2026-02-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two of three residents (R1, R2) reviewed for abuse on the sample of four.Findings include:The facility's Abuse Prohibition policy with the revision date of 8/25/25 documents the facility affirms the residents' right to be free from abuse. The policy states that all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. R1's Medical Diagnosis list dated February 2026 documents diagnoses of Fibromyalgia, Dementia without Behavioral Disturbances, and Psychosis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired, has physical/verbal behavioral symptoms one to three times a week, requires the use of a wheelchair for mobility, and requires substantial to maximum assistance for all activities of…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-04 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to revise a care plan after an incident of resident to resident physical abuse. This failure affects one of three residents (R1) reviewed for abuse on the sample list of four. Findings include:The Facility Reported Incident Investigation dated 12/6/25 documents R1 hit R2 in the hall while they were talking to each other. The incident was witnessed by R4.R1's Medical Diagnosis list dated February 2026 documents diagnoses of Fibromyalgia, Dementia without Behavioral Disturbances, and Psychosis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired, has physical/verbal behavioral symptoms one to three times a week, requires the use of a wheelchair for mobility, and requires substantial to maximum assistance for all activities of daily living. (ADL's). R1's Care Plan dated reviewed 1/27/26 did not address the incident of abuse which took place on 12/6/25 between R1 and R2. There were no problems or interventions on R1's care…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-30 · 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 and interview the facility failed to maintain a homelike environment by failing to maintain linen in good condition. This failure affected two of twelve residents (R25, R33 ) reviewed for homelike environment on the sample list of 36. 1. On 7/27/2025 at 10:39 AM R25 stated the towels are worn and have frayed edges and holes. R25 held up a towel with worn, frayed edges and two washcloths with frayed edges on every side. R25 stated she doesn't understand why the staff don't get rid of the worn linen and instead provide linen that is in good shape for residents to wash up with. R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. 2. On 7/28/25 at 8:06 AM R33 stated the edges of towels get frayed. There was a wet washcloth on bathroom sink with frayed, stringy edges. R33 held up another washcloth that had frayed edges with golf ball sized hole along edge. R33 stated he has seen worse than those and with such a nice place you would think they would provide nicer towels…

    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 before2025-03-19 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to timely report an injury of unknown origin to the physician and resident representative. The facility also failed to report changes in medication orders to the resident representative for two (R1, R2) of six residents reviewed for changes in condition in the sample list of 12. Findings include: 1.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment. R1's Nursing Note dated 8/12/2024 at 9:58 AM documents new orders were received to stop Plavix. There is no documentation in R1's medical record that this new order was reported to V27 (R1's Family). On 3/19/25 at 10:42 AM V3 (Assistant Director of Nursing/ADON) stated V3 attempted to contact V27 the day R1's Plavix was discontinued, but V3 forgot to document that V3 left a message for V27. V3 reviewed R1's nursing notes and confirmed there was no documentation that V27 was notified of Plavix being discontinued. The facility's Guidelines for Physician Notification 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-19 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report allegations of abuse and timely report an injury of unknown origin to the facility's administrator and the state surveying agency for three (R1, R2, R6) of eight residents reviewed for abuse in the sample list of 12. Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents allegations of abuse must be immediately reported to the facility's administrator and the administrator will provide an initial notice of the allegation to the (state surveying agency) immediately after the allegation is known. This policy documents injuries of unknown origin, including significant bruises must be immediately reported to the charge nurse, Director of Nursing (DON) and Administrator. The charge nurse will document the nature of the injury in the resident's medical record, complete an incident report describing the injury and the circumstances of the injury, and notify the physician and resident's representative. Injuries of unknown…

    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
Show the remaining 13 citations
  • Potential for harm · D2025-03-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond 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 investigate allegations of abuse and to implement protective measures following reported allegations of abuse for three (R1, R2, R6) of eight residents reviewed for abuse in the sample list of 12. Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents after allegations of abuse are reported to the (state surveying agency), the alleged incident will be investigated by the Administrator or designee and the results of the investigation will be reported to (state surveying agency). The Administrator is responsible for protecting the resident from retaliation during and after the investigation. When an employee is the alleged perpetrator of the abuse, the employee shall be immediately barred from any further contact with residents in the facility until the outcome of the investigation is determined. The facility's Abuse Tracking Log with last recorded entry as 5/5/24 does not document any allegations of abuse involving R1, R2, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-19 · 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 implement fall interventions, document a fall in the medical record, perform safe and proper transfers, and thoroughly investigate falls for three (R1, R2, R6) of three residents reviewed for accidents in the sample list of 12. Findings include: The facility's Fall Assessment and Management Policy dated June 2024 documents the following: The resident's care plan will reflect specific needs and risk for falls and all staff who provide resident care will have access to the care plan and/or (electronic care report). Interventions will be based on the fall risk assessment and circumstances of each fall. The nurse will assess the resident following a fall and document on the resident's condition for 72 hours after the incident. The facility's Safe Resident Handling Program dated 3/18/18 documents the resident transfer status will be documented on the resident's plan of care and reviewed via the care plan time frames and as needed. This policy…

    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 · F2024-06-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to label a refrigerated, plastic container of chopped onions and a refrigerated, plastic container of chopped tomatoes with any dates and failed to monitor temperature cooking times to ensure that food is being served safely. These failures have the potential to affect all 72 residents who reside in the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/3/24 documents 72 residents reside in the facility. The facility provided Food Storage Chart dated 2/2022 documents that after a food item is opened, it will be covered, labeled, use by date will be put on, initialed and stored. On 6/3/24 at 9:10AM during the initial tour, chopped onions and tomatoes were stored in the refrigerator without any time or date label. On 6/3/24 at 9:11AM, V9 Dietary Manager said that the onions and tomatoes should have been dated when they were chopped and put into the refrigerator and now needed to be thrown away. Additionally, V9 Dietary Manager said that the onions 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-05 · tag F0604 — failed to not use physical restraints improperly — pattern
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 have orders, consents or assessments for R52 and R219, failed to complete an initial assessment for a soft waist restraint for R47 and failed to obtain a consent for a soft waist restraint for R55 for four of four residents (R47, R52, R55, R219) reviewed for restraints on a sample list of 42 residents. Findings include: The facility Restraint Program Policy and Procedure dated 11/10/15 documents that prior to the use of any restraint, each resident is assessed for potential alternative by using the restraint Pre-Restraining and Quarterly Evaluation. If a restraint is deemed appropriate, a consent will be obtained, a quarterly review of the restraint will be completed, the care plan will be updated and reduction attempts will be documented. 1.) R52's Minimum Data Set, dated [DATE] documents that R52 is severely cognitively impaired. R52's progress notes document that on 5/17/24, the body pillow was in use on R52's bed. R52's medical record…

    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 · E2024-06-05 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 administer medications as ordered and in accordance with manufacturer's instructions for three (R7, R270, R59) of 11 residents reviewed for medication administration in the sample list of 42. This failure resulted in four medication errors out of 25 opportunities, a medication error rate of 16%. Findings include: 1.) R7's June 2024 Medication Administration Record (MAR) documents Metamucil Powder 28.3 % (Psyllium) Give 12 gram by mouth in the evening for constipation Drink at least 8 oz (ounces) of cool liquid per dose scheduled daily at 4:00 PM. On 6/03/24 at 4:38 PM V13 Registered Nurse (RN) administered R7's medications including 1/2 teaspoon of Metamucil dissolved in water. The Metamucil label documented one tablespoon equals 12 grams. V13 confirmed 1/2 teaspoon of Metamucil was administered. On 6/04/24 at 11:48 AM V16 RN stated R7 receives Metamucil and the dose is 12 grams. V16 read the Metamucil label and confirmed one tablespoon is 12 grams. 2.) R270's June 2024 MAR documents to administer Humalog…

    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 · E2024-06-05 · 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 ensure medications were labeled with the resident's full name and opened dates, ensure medications were not used past the beyond use date, and discard medications for eight (R1, R6, R269, R62, R53, R59, R44, R9) of 18 residents reviewed for medication storage on the sample list of 42. Findings include: On 6/04/24 at 12:12 PM the C side medication cart was viewed with V15 Registered Nurse (RN). R1's Lispro insulin pen was labeled with an opened date 4/12/24 (past the beyond use date). R6's Basaglar insulin pen was not labeled with an opened date. There was a Novolog (Aspart) insulin pen that did not contain a resident's name, only R269's nickname, or an opened date. V15 verified the labeling of these medications. V15 stated the pen belonged to R269, and confirmed it was not labeled with R269's full name. V15 stated V15 thinks insulin is good for 30 days once opened. On 6/04/24 at 12:38 PM the A Wing medication cart was viewed with V16 RN. R62's Latanoprost (Xalatan) eye drop bottle was labeled with an opened…

    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 · D2024-06-05 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 obtain a level II PASRR (Preadmission Screening and Review) for one resident (R57) with Post-traumatic Stress Disorder (PTSD) of one resident reviewed for PASRR in a sample list of 42 residents. Findings Include: R57's Minimum Data Set (MDS) dated [DATE] documents R57 has an active diagnoses of PTSD and is cognitively intact. R57's Diagnoses list includes a diagnosis dated 6/30/23 of PTSD. There is no evidence in the medical record the facility obtained a Level II PASSR screening when they became aware of R57's diagnosis of PTSD. On 6/5/24 at 1:00PM V1, Administrator stated I was not aware that if the Level I PASRR did not indicate a Level II we had to get a level II in the event we became aware of a diagnosis of a serious mental Illness. V1 also verified that while the facility's policy for Care Plan Procedure does state the PASRR recommendations will be included in the initial Care Plan the facility does not have a policy specific to when to obtain 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-05 · 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 shave two (R12 and R17) of two dependent residents reviewed for dependent activities of daily living on a sample list of 42 residents. Findings include: The facility provided A.M. (morning) Care procedure dated April 2009 documents that staff are to provide personal hygiene to residents in the morning. This includes providing assistance with shaving including a razor, shaving cream and a basin of warm water. 1.) R17's Functional assessment dated [DATE] documents that R17 is dependent for all activities of daily living. On 6/3/24 at 9:47AM, R17 had whiskers all over his face and neck, approximately 1/2 inch long. On 6/3/24 at 9:50AM, R17 said that he liked to be clean shaven and that he really misses that here. On 6/3/24 at 9:55AM, V17 Certified Nursing Assistant asked R17 if he would like to be shaved and he responded in the affirmative. On 6/5/24 at 9:35AM, R17 had beard growth of 1/4 inch. On 6/5/24 at 9:30AM, R17 said that he is unable…

    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 before2024-06-05 · 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

    Based on observation, interview and record review the facility failed to complete a safe sit to stand mechanical lift transfer for one (R55) of four residents reviewed for falls in the sample list of 42. Findings include: R55's diagnosis list documents diagnoses including Dementia, Contracture of the Right Knee, Contracture of the Left Knee, Muscle Weakness, Muscle Wasting, Abnormal Posture and Obesity, Anxiety and Depression. R55's Physical Therapy Evaluation and Plan of Treatment signed on 12/18/23 documents R55's goals of therapy were to increase knee range of motion and strength to be able to continue to use the stand lift. On 6/3/24 at 12:10 PM, V5 Certified Nursing Assistant (CNA), V6 and V7 CNA students wheeled R55 into the central bathroom to assist R55 to the toilet. They removed the soft lap cushion and wheeled her close to the mechanical sit to stand lift. They placed her feet on the foot plate and placed the sling under her arms and around her back, and placed the loops of the sling in the hooks on the lift. They raised R55 with the mechanical sit to stand lift. They did…

    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 · D2024-06-05 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 identify potential triggers and implement resident centered trauma based interventions for one resident (R57) with Post-traumatic Stress Disorder (PTSD) of one resident reviewed for PTSD in a sample list of 42 residents. Findings Include: The facility's policy Trauma Informed Care dated 1October 2022 states It is the policy of this facility to ensure that residents who are trauma survivors receive culturally competent, trauma informed care. Resident experiences and preferences will be taken into account in an effort to eliminate or mitigate triggers that could cause retraumatization. This policy also states The Interdisciplinary team will work with the resident as well as family if indicated and other healthcare providers to develop and implement resident specific investigations in an effort to avoid re-traumatization. The team will also identify ways to mitigate or decrease the effect of the trigger in the resident. Trauma specific…

    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 · D2024-06-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to perform hand hygiene before and after eye drop and insulin administration for two (R59, R62) of 11 residents reviewed for medication administration in the sample list of 42. Findings include: The facility's Medication Administration policy dated 1/11/2010 documents Wash hands according to facility protocol. Wash prior to med (medication) pass, after administering eye preparations, after removing gloves and when hands become soiled. On 06/03/24 at 4:43 PM V13 Registered Nurse applied gloves and injected Admelog insulin 2 units into R59's abdomen. V13 removed and discarded the gloves. At 4:47 PM V13 applied gloves and administered Timolol Maleate 0.5 % one drop to R62's left eye. V13 removed and discarded the gloves, and left R62's room. V13 did not perform hand hygiene prior to or after administering R59's insulin and R62's eye drops. On 6/03/24 at 4:52 PM V13 stated hand hygiene during medication pass should be done when leaving the resident's room. V13 confirmed V13 did not perform hand hygiene before 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-12 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify a resident's (R38) primary care physician of repeated refusal to take prescribed medications. This failure affects one resident (R38) of 12 residents reviewed for medication in the sample list of 30. Findings include: R38's Physician Order Sheet (POS) dated 5/11/23, documents Aspirin Tablet Delayed Release 81 milligram give one tablet by mouth in the morning, Calcium 600+D Tablet 600-400 milligram-unit (Calcium Carbonate -Vitamin D) give one tablet by mouth in the morning, Cholecalciferol Tablet 50 micrograms (2000 UT) give one tablet by mouth in the morning, Cranberry Tablet 450 milligrams give one tablet by mouth in the morning for prevention of urinary tract infection, Docusate Sodium Oral Tablet 100 milligrams give one tablet by mouth two times a day, Gemfibrozil Tablet 600 milligrams give one tablet by mouth two times a day, Losartan Potassium Tablet 100 milligrams give one tablet by mouth in the morning, Memantine HCI five milligrams one…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-12 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 a significant medication error by leaving eleven ordered morning medications at a resident's bedside. This failure affects one resident (R38) of 12 residents reviewed for medication administration observation in the sample list of 30. Findings include: R38's Physician Order Sheet (POS) dated 5/11/23, documents Aspirin Tablet Delayed Release 81 milligram give one tablet by mouth in the morning, Calcium 600+D Tablet 600-400 milligram-unit (Calcium Carbonate -Vitamin D) give one tablet by mouth in the morning, Cholecalciferol Tablet 50 micrograms (2000 UT) give one tablet by mouth in the morning, Cranberry Tablet 450 milligrams give one tablet by mouth in the morning for prevention of urinary tract infection, Docusate Sodium Oral Tablet 100 milligrams give one tablet by mouth two times a day, Gemfibrozil Tablet 600 milligrams give one tablet by mouth two times a day, Losartan Potassium Tablet 100 milligrams give one tablet by mouth…

    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

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to HERITAGE OPERATIONS GROUP — 9 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 →

RatingThis homeChain avg
Overall 4 of 52.0+2.0 vs chain
Health inspection 4 of 52.7+1.3 vs chain
Staffing 3 of 51.7+1.3 vs chain
Quality measures 2 of 51.6+0.4 vs chain
The other 8 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 / managerTypeRoleSince
BROWN, PAIGEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/08/2022
GRESS, LONIIndividualCORPORATE DIRECTORsince 06/01/2024
HART, STEVENIndividualCORPORATE DIRECTORsince 07/01/2023
LOUNSBURY, KARLAIndividualCORPORATE DIRECTORsince 07/01/2023
MCFADDEN, DAVEIndividualCORPORATE DIRECTORsince 05/24/2022
NICHOLLS, WILLIAMIndividualCORPORATE DIRECTORsince 05/24/2022
RAY, DARRINIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/21/2021
TOTHEROH, BRANDIIndividualCORPORATE DIRECTORsince 08/01/2022
TUCKER, HEATHERIndividualCORPORATE DIRECTORsince 03/11/2022
WILSON, CONNIEIndividualCORPORATE DIRECTORsince 05/24/2022
CURRY, DANIELIndividualCORPORATE OFFICER; ADP OF THE SNFsince 01/07/2025
HERITAGE OPERATIONS GROUP, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/22/2022
HART, BENJAMINIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/05/2014

CMS files one row per role, so the 19 rows in the source record cover these 13 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.

1 organizational owner 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.

$7.0M
Net patient revenuemost recent cost report
-7.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 62%Medicare 3%Other / private 35%

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

$302per resident / day
operating cost
$9,192per month
≈ monthly operating cost
$281per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145470. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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