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Prairie Village Healthcare Ctr

1024 West Walnut, Jacksonville, IL 62650 · For profit - Corporation · 126 certified beds · (217) 245-5175 Medicare & Medicaid certified

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1 immediate-jeopardy citation$131,684 in federal fines2 Medicare payment denials
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $131,684 in federal fines (most recent 2026-04-23)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (65%) runs well above the national median (45%)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1440 W Walnut St Ste 2A · (217) 243-3543 · Call to confirm hours
Pharmacy
901 W Morton Ave · (217) 245-9100 · Call to confirm hours
Grocery
1111 Carnation Dr · (217) 243-9175 · Call to confirm hours
Park
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 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 1 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 fell from 3 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased13.6%13.4%15.4%better
Long-stay residents who lose too much weight8.6%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder2.1%0.9%0.9%worse
Long-stay residents with a urinary tract infection2.9%1.5%2.0%worse
Long-stay residents with depressive symptoms97.5%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury5.5%3.1%3.3%worse
Long-stay residents whose ability to walk worsened14.3%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication26.5%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine95.7%91.8%95.3%typical
Long-stay residents with pressure ulcers17.1%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control13.8%20.6%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table27.1%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.9%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine25.0%63.1%79.4%worse
Short-stay residents rehospitalized after admission22.9%26.1%22.6%typical
Short-stay residents with an outpatient ER visit23.1%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.252.021.67worse
Long-stay outpatient ER visits per 1,000 resident days7.472.221.80worse

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.

53.4% 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 26 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

53.4%U.S. median 51.5%
Got home and stayed home
12.3%U.S. median 10.7%
Went back to hospital
0.40U.S. median 0.31
Therapy hours / resident / day
0.15hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% 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 SNF53.4%CMS range 34.5–70.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.3%CMS range 9.2–15.910.7%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened7.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.4%CMS range 4.2–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.581.02Oct 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

0.57
RN hours/ resident / day
0.88
LPN hours/ resident / day
2.39
Aide hours/ resident / day
3.84
Total nurse hours/ resident / day
0.30
RN hoursweekends
65.2%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 126 beds and averages 56.2 residents a day — about 45% occupied, or roughly 70 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 3.84 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.39 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.91 hrs/resident/day on weekends vs 4.22 on weekdays — 31% thinner on weekends — a notable drop. RN hours go from 0.67 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

3
deficiencies at the latest standard inspection (2024-04-11)
5
at the previous standard inspection (2023-05-10)

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.

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.

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2026-04-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on interview and record review the facility failed to obtain a urine sample timely and properly insert a catheter for 1 of 5 residents (R13) reviewed for urinary tract infections in the sample of 27. This failure resulted in the untimely collection of a urine specimen, with collection not occurring until 4 days after the order was received. During this time R13 suffered increasing symptoms with ultimately a malposition foley catheter being inserted into R13's urethra with a partially inflated balloon, despite the order given being for a straight catheter. R13 developed urosepsis and septic shock with hospital stay from [DATE]-[DATE] with ICU care for 7 days and ultimately death on [DATE] caused by sepsis and UTI.The immediate jeopardy began on [DATE] when R13 was transferred to local hospital due to change in condition in which the facility had not obtained a urine sample. R13's labs at the local hospital indicated R13 had a UTI. The facility inserted a foley catheter improperly causing obstruction,…

    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 · G2022-06-16 · 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 provide supervision to prevent falls, investigate falls thoroughly to determine a root cause analysis and implement progressive interventions to prevent falls, provide safe transfers, and ensure transfer equipment is in good condition for 5 of 8 residents (R9, R10, R14, R17, R27) reviewed for falls and transfers in the sample of 31. This failure resulted in R17 falling 5 times,sustaining bumps to the back of her head, and another fall resulting in R17 going to the emergency room and receiving 8 staples to the back of her head. Finding include: 1.R17's Face Sheet, undated, documents R17 was admitted on [DATE] and has diagnoses of cerebral infarction, dementia with behavioral disturbance, anxiety, personal history of (healed) traumatic fracture of right tibia and left femur. R17's Minimum Data Set (MDS), dated [DATE], documents R17 is severely cognitively intact, has inattention and disorganized thinking that fluctuates and changes in…

    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 · Ecited before2026-04-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to don Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precaution (EBP) and Contact Isolation, and to do hand hygiene and glove changes when necessary for 4 of 4 residents (R9, R12, R15, R21) reviewed for infection control in the sample of 30.The findings include: 1. R9's Face Sheet, dated 4/6/26, documents R9 was admitted to the facility on [DATE].R9's Physician Order, dated 4/17/26, documents Strict Isolation Type: Contact: Wound- Abdominal Wall Cellulitis, follow Contact Isolation.On 4/7/26 at 8:55 AM, a Contact Isolation sign was seen on R9's door with Personal Protectant Equipment (PPE) hanging on the door. Both V14, Licensed Practical Nurse (LPN)/Wound Nurse, and V7, Certified Nursing Assistant (CNA), entered R9's room for wound care with no PPE on. Before, during, or after wound care, there was no PPE worn except for gloves.2. R12's Face Sheet, dated 4/6/26, documents R12 was originally admitted to the facility…

    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 before2026-04-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to properly treat pressure sores, including following physician orders, for 1 of 4 residents (R9) reviewed for care of a pressure ulcer in the sample of 30. The findings include:1. R9's Face Sheet, dated 4/6/26, documents R9 was admitted to the facility on [DATE].R9's Care Plan, dated 3/25/26, documents R9 has alteration in skin integrity as evidence by pressure ulcer, wound healing may be hindered due to resident noncompliance with being turned every two hours, and offloading her buttocks, resident prefers to lay on her back. Interventions: Encourage/assist with turning/repositioning every two hours and PRN (as needed), keep clean and dry as possible, minimize skin exposure to moisture, provide/assist with continence care as needed, keep linens dry and wrinkle free to prevent further pressure forces, maintain head of bed at/or below 30 degrees or at lowest degree of elevation consistent with the resident's medical condition to prevent…

    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 · D2026-04-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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

    Based on interview and record review the facility failed to replace a broken c-pap mask timely for 1 of 3 residents (R1) reviewed for respiratory therapy in the sample of 30. Findings include:1 R1's progress notes dated 2/2/2026 at 2;57PM documents Resident's c-pap mask is broke, and medical supply company is bringing a new one tomorrow 2/3. Oxygen on at 3L (liters)/NC. (nasal cannula)R1's progress notes dated 2/1 2026 at 11:37PM documents Resident complained of Shortness Of Breath (SOB) at bedtime (hs). Nebulization treatment administered per order. Post-treatment SpO2 improved to 92%. Noted mask is broken and requires replacement; Resident continues to be monitored for further respiratory distress, on continuous O2 therapy via at 4L via nasal cannulaR1's undated face sheet documents a diagnosis in part of Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory failure wit hypoxia, Dependent on supplemental oxygen, and obstructive sleep apnea. R1's physician orders dated 1/31/2026 documents 02 (oxygen) at 3L (liters) per nasal cannula if refuses c-pap or if not available…

    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 · D2026-04-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to administer an antibiotic to a resident with a diagnosis of Urinary Tract Infection (UTI) and failed to follow physician orders to administer medications for 2 of 5 residents (R21, R22) reviewed for medication administration in the sample of 30.The findings include:1. R21's Face Sheet, dated 4/7/26, documents R21 was originally admitted to the facility on [DATE].R21's Care Plan, dated 4/6/26, documents R21 requires a suprapubic catheter related to urinary retention. Interventions: Enhanced barrier precautions, keep catheter system a closed system as much as possible, document urinary output every shift, record the amount, type, color, odor, observe for leakage. R21's Minimum Data Set (MDS), dated [DATE], documents R21 is cognitively intact and is dependent on staff for toileting. R21 has urinary catheter in place and is frequently incontinent of bowel.R21's Hospital Record, dated 4/10/26, documents in part Patient presented to the ER…

    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 · D2025-10-24 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    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 a residents' foot was free of insects for 1 of 3 residents (R2) reviewed for foot health. Findings include: R2's Undated Face Sheet, documents she was admitted to the facility on [DATE]. No diagnosis of wounds or bugs on R2's skin, including maggots. R2's Minimum Data Set (MDS) dated [DATE] documents she is alert. R2's Care Plan, dated 10/20/2025 documents R2 has an open lesion on the foot which appears to be small crack in the skin between her 4th and 5th toe on her right foot. Goal: lesion will show improvement by decreasing in size and showing no signs and symptoms of infection by next review date. Approaches: administer dressing/treatment to address/stabilize specific wound characteristics as ordered by the physician, encourage appropriate footwear is worn at all times and encourage R2 not to walk/propel chair around barefoot or in just socks/stockings, ensure footwear for proper sizing, ensure shoes are in good condition,…

    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 · D2025-10-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    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 maintain a complete and accurate medical record for 1 (R2) of 3 sampled residents in review of complete and accurate medical records. Findings include: R2's Undated Face Sheet, documents she was admitted to the facility on [DATE]. No diagnosis of wounds or bugs on R2's skin, including maggots. R2's Minimum Data Set (MDS) dated [DATE] documents she is alert. On 10/24/2025 at 3:33 PM V5, LPN stated V13, Facility Podiatrist entered the facility early in the morning on 10/20/2025 and assessed residents, including R2. R2's Electronic Medical Record (EMR) dated 10/23/2025 no documentation of V13's progress notes. On 10/23/2025 at 2:20 PM V1, Administrator stated V13, Facility Podiatrist doesn't share/send his progress notes with the facility, and he never has. On 10/24/2025 at 11:54 V13, R2's Podiatrist stated he is the facility podiatrist, and sees over 25 plus patients at the facility approximately four times a year. V13 stated his office sends the facility…

    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 · D2025-06-30 · 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, observation and record review, the facility failed to follow physician's orders for twice-daily pulse oximetry checks for 2 of 3 residents (R1 and R2) reviewed for quality of care in the sample of 4. Findings include: 1. R2's undated face sheet documented he was admitted to the facility on [DATE] and has the following diagnoses polyneuropathy, diabetes, end stage renal disease, dependence on dialysis, right below the knee amputation, and obstructive sleep apnea. R2's minimal data set (MDS) dated [DATE] documented he is cognitively intact. R2's care plan updated 6/5/25 documented wound care interventions, depression, peripheral neuropathy, dialysis, pain, nutrition, and diabetes. There was no problem including oxygen saturation monitoring noted in his care plan. R2's physician order dated 4/21/25 documented Oxygen: Oxygen saturation (pulse oximetry) (SPO2) twice daily. R2's oxygen saturation recordings reviewed in the electronic medical record (EMR) and documented daily except for 6/5/25 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to identify a stage 2 pressure ulcer on the upper intergluteal cleft in a timely manner for 1 of 3 (R2) residents reviewed for pressure ulcers in a sample of 4. Findings include: R2's undated face sheet documented he was admitted to the facility on [DATE] and has the following diagnoses polyneuropathy, diabetes, end stage renal disease, dependence on dialysis, and right below the knee amputation. On 6/25/25 at 9:40 am during skin check of R2's buttocks area with V3 Licensed Practical Nurse (LPN)/ wound nurse, V5 (LPN/wound nurse) and surveyor, a new pressure wound to upper intergluteal cleft was found measuring 0.5 cm x 0.2 cm which V3 acknowledged was a stage 2 pressure wound. V3 and V5 stated they were unaware of a pressure wound to this area. On 6/25/25 at 10:30 am, V3 stated she had received orders from V15 (Facility Physician) and was bringing in wound care supplies to provide wound care to the new upper intergluteal pressure wound. R2's…

    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 · Fcited before2024-04-11 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview, and record review, the facility failed to provide 8 consecutive hours of Registered Nurse (RN) Coverage. This failure has the potential to affect all 48 residents residing in the facility. Findings include: The Schedule, dated 3/4/24 - 3/17/24, fails to document a Registered Nurse working for 8 consecutive hours on 3/5/24, 3/6/24, 3/7/24, 3/8/24, 3/10/24, 3/11/24, 3/13/24, 3/16/24 and 3/17/24. On 4/10/24 at 1:30 PM, V1, Administrator, stated, (V14), (previous Director of Nurses, (DON) ended her employment on 1/18/24. (V15), (Interim DON) worked from 1/18/24 until 3/4/24 as the sitting DON. Then (V15) just quit and that is when I lost my RN coverage. The Long-Term Care Facility Application for Medicare and Medicaid, dated 4/8/24, documents that 48 residents reside in the facility.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-11 · tag F0880 — failed to prevent and control infections — pattern
    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 interview, observation and record review, the facility failed to cleanse a multi-use blood glucose machine completely to insure disinfection for 7 of 16 residents (R4, R12, R17, R23 R38, R45, R47) reviewed for infection control in the sample of 29. Findings include: On 4/8/24 at 11:03 AM, V4, Licensed Practical Nurse, entered (R38's) room to obtain a blood glucose level. V4 got the level of 158 and exited the room. V4 took the blood glucose machine to her medication cart and laid it on a clean tissue. V4 obtained a Microdot Bleach wipe and gently wrapped the machine up and placed it on top of her medication cart. V4 set a timer for 3 minutes. V4 failed to rub the entire machine with the Microdot cloth. On 4/9/24 at 11:00 AM, V1, Administrator stated that the blood glucose machine should be cleansed before wrapping it up. The facility provided list documenting who gets blood glucose monitoring, dated 4/10/24, documents that R4, R12, R17, R23, R38, R45 and R47 all use this multi-use glucose monitor. The Microdot Bleach Wipe container ,documents, Disinfection: 5. Apply…

    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
Show the remaining 10 citations
  • Potential for harm · Dcited before2024-04-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to provide the Physician Ordered treatment to pressure sore to left heel for one of 3 residents ( R10) reviewed for pressure ulcers in the sample of 29. Findings include: 1. On 04/10/24 at 2:46PM during a dressing change and treatment V10, Licensed Practical Nurse (LPN)/ wound nurse, removed boots from R10's feet. R10's left heel boggy and black circular area unopened and left metatarsal open area 2 inches in diameter scabbed . V10 stated metatarsal is to be open to air. V10 wound nurse removed dressing from R10's left heel. R10's left heel had a mesh gauze occlusive impregnated with vaseline dressing underneath padding covering R10's pressure sores. V10, Wound nurse stated there is no order for that dressing to R10's left heel. R10's wound management progress notes dated 3/26/2024 documents, skin moisturizer to left heel daily, cushion with abdominal pad or foam heel cup and may secure with kerlix or gauze wrap. R10's care plan dated 10/12/2023 documents R10 has an alteration in skin integrity. R10's care plan…

    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 · Fcited before2023-05-10 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, the facility failed to provide 8 hours of consecutive Registered Nurse coverage. This failure has the potential to affect all 55 residents living in the facility. Findings include: On 05/09/23 at 11:02 AM, V1, Administrator, stated, that some weekends she is short a few hours for Registered Nurse, (RN), coverage. The facility Nurse Schedule, dated 03/01/23 - 05/07/23, was reviewed. These schedules failed to document eight hours of consecutive RN coverage on 05/06/23, 04/22/23, 04/23/23, 04/08/23, 04/09/23, 03/25/23 and 03/26/23. The Resident Census and Conditions of Residents, CMS 672, dated 05/08/23, documents that the facility has 55 residents living in the facility.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-05-10 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to employ a trained Infection Preventionist. This failure has the potential to affect all 55 residents living in the facility. Findings include: On 05/09/23 at 11:15 AM, V3, Registered Nurse, stated, I stated on 02/28/23. I do not have the infection prevention certificate. I am being trained by, V7 Corporate Infection Preventionist. I talk with him via email and telephone. On 5/9/23 at 11:15 AM, V1, Administrator, stated, that V7 comes in once a month he does training and reviews the infection control logs. Part time is considered anything less than 32 hours a week. The policy Infection Prevention and Control Program (ICPCP), dated 2019, documents, The facility will designate one or more individual(s) as the infection preventionist (s) (IP) (s) who is responsible for the facility's IPCP. The infection preventionist will: a. Have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field: b. is qualified by education, training, experience or certification. c. Works 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-10 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. R49's Care Plan, dated 4/28/23, documents ADLs, (activities of daily living), Functional Status/Rehabilitation Potential PROBLEM: (R49) admitted to facility from outlying hospital after suffering from a Cerebral infarct. (R49) has dx of, but not limited to: Huntington's disease, HTN, (Hypertension), atherosclerotic heart disease, autoimmune thyroiditis, type II diabetes, hyperlipidemia, hemiplegia, and hemiparesis to right side following CVA, (Cerebral Vascular Accident), dysphagia, abnormalities in gait and mobility, urinary retention, and convulsions. (R49) has an upper and lower partial. 6/15/22 June is able to ambulate short distances with two staff and a gait belt. Her primary mode of locomotion is a w\c, (wheelchair), that she requires assistance to propel. (R49) is alert and able to voice needs. It continues, APPROACH: Provide toileting assistance at least every 2 hours, PRN, (as needed), and upon any request. Document bowel and bladder tracking daily every shift. Notify nurse if (R49) has no BM,…

    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 before2023-05-10 · 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 interview, observation and record review, the facility failed to perform hand hygiene and change soiled gloves to prevent cross contamination for 3 of 24 residents (R12, R19, R49) reviewed for infection control in the sample of 28. Findings include: 1. On 05/07/23 at 10:48 AM, V6, Certified Nurse Assistant, (CNA), entered R12's room to assist R12 to the restroom, using a gait belt and a walker. R12's incontinent brief was wet with urine. While on the toilet R12 placed her hand into the inside of the bottom of brief. R12 was assisted back to bed for incontinent care. V6 failed to offer to assistance with washing R12 hands. The incontinent care was provided in bed with assist from, V8 CNA. V6 cleansed the peri-vaginal area and then dried it with a towel. V6 draped the towel over R12's walker bars. 2. On 05/08/23 at 8:07 AM, V4, Licensed Practical Nurse, (LPN), prepared an insulin injection for R19. V4 pushed, R19 in her wheelchair to her room. V4 donned gloves and gave the insulin, subcutaneous injection in the right lower abdominal quadrant. V4 failed to perform hand hygiene…

    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 · D2023-05-10 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 educate residents and offer the Pneumococcal Immunizations yearly, to residents that had previously refused it, for 2 of 5 residents (R32, R46) reviewed for immunizations in the sample of 28. Findings include: On 05/08/23 at 12:58 PM, V1, Administrator, stated, that she did not realize that once a resident refused the Pneumococcal Vaccine that it should be offered to them every year. 1. R32's Pneumococcal Vaccine Record, dated 03/16/20, documents that R32 refused the vaccine. In handwriting on this Record, it reads, Due for refusal/consent 03/2025. R32's Face Sheet, undated, documents that R32 was admitted on [DATE] and has diagnoses of Dementia and personal history of COVID 19. 2. R46's Pneumococcal Vaccine Record, dated 11/16/21, documents that R46 refused the vaccine. In handwriting on this Record, it reads, Due for refusal/consent 11/2026. R46's Face Sheet, undated, documents that R46 was admitted on [DATE] and has diagnoses of Dementia and Chronic…

    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 · F2022-06-16 · tag F0761 — failed to label and store drugs safely — widespread
    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/secure medication, label insulin and tuberculin vials when opened and discard expired medications. This has the potential to affect all 57 residents living in the facility. Findings include 1.On 6/14/2022 at 9:00 AM the 300 Hall medication cart was inspected. The medication cart contained the following medication: R24's Humalog Vial with open date 5/2/22 and expiration date 5/30/22 handwritten on the bottle. On 6/14/2022 at 9:12 AM V11, Licensed Practical Nurse (LPN), stated that the Humalog vial was open and in use. V11 stated that the medication was expired. V11 stated that the Humalog should not be used and thrown away. The Humalog Manufacture insert documents Store at room temperature and use within 28 days. 2.On 6/14/2022 at 9:20 AM the facility's 400 hall medication storage room was inspected. The refrigerator, located in the medication storage room on 400 Hall, contained the following: 1 vial of Tuberculin vial, labeled facility stock. The vial was unlabeled as to when it was 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 · Ecited before2022-06-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide complete incontinence care to 4 of 6 residents (R14, R17, R39, R50) reviewed for incontinence care in a sample of 31. Findings include: 1. On 6/13/2022 at 12:30 PM V9, Certified Nurse Aide (CNA), and V10, CNA, performed incontinent care. V9 and V10 transferred R39 into the bed from the wheelchair revealing a urine soak bed pad in wheelchair. V9 and V10 turned R39 onto his right side. R39 was incontinent of a large amount of bowel. V10 cleansed R39's anal area and left buttock. V9 and V10 assisted R39 onto his left side and V9 cleansed R39's right buttock. V9 and V10 rolled R39 onto his back and pulled covers over R39. V9 and V10 did not cleanse R39's penis, scrotum, peri area, and inner thighs. R39's Care Plan, last review date 4/26/2022, documents Problem: (R39) is incontinent of bowel and bladder. It continues Provide incontinence care after each incontinent episode. The Care Plan documents Apply moisture barrier to skin after…

    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 · Ecited before2022-06-16 · tag F0880 — failed to prevent and control infections — pattern
    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, failed to perform hand hygiene before donning gloves and after removing gloves, change gloves when soiled and dispose of soiled dressings appropriately for 4 of 15 residents (R14, R25, R27, R39) reviewed for infection control in the sample of 31. Findings include: 1. On 6/15/22 at 11:55 AM, V12, Certified Nurse Aide and V14, Licensed Practical Nurse (LPN) both entered R25's room, both donned gloves with no hand hygiene to assist him to stand to use the urinal. 2. On 6/14/22 at 12:58 PM, V13 CNA and V12 transferred R14 using a mechanical lift to bed and then placed R14 on a bed pan. V13 donned gloves without hand hygiene and changed gloves 2 times without hand hygiene during incontinent care. On 6/16/22 at 4:15 PM, V1, Administrator, stated that staff should be performing hand hygiene before putting gloves on and after taking them off. 3. On 6/14/2022 at 10:00 AM R27 was lying in bed with peanut butter sandwich on bedside table. V3, Wound Nurse, performed treatment to R27's right and left foot. V3 placed clean treatment supplies,…

    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 · D2022-06-16 · tag F0759 — failed to keep medication error rate low — isolated
    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, record review and interviews the facility failed to administer medications as prescribed and at scheduled time. There were 29 opportunities with 2 errors resulting in 6.9% medication error rate. The errors involved 2 residents (R24, R30) in the sample of 31 out of 4 residents observed during medication administration. Findings include: 1. 06/15/22 at 1:22 PM R24's Physician's Order Sheet (POS), dated 6/3/2021, documents Humalog per sliding scale insulin: If Blood Sugar is 70 to 149, give 0 units. 150-199 give 2 units, 200-249 give 3 units, 250-299 give 5 units, 300-349 give 7 units, If blood sugar greater than 349 give 8 units subcutaneous 4 times daily. If blood sugar is greater than 349 notify MD Frequency: Before Meals and At Bedtime. On 6/14/2022 at 9:15 AM, after breakfast, V11, Licensed Practical Nurse (LPN) was passing medications. V11 performed R24's 6:00 AM blood glucose monitoring. R24's results were 183 indicating 2 units of Humalog Insulin required. V11 then administered R24's Humalog 2 units. On 6/16/2022 at 1:08 PM V28, LPN, stated that when…

    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

$131,684 in federal fines across 1 penalty. 2 Medicare payment denials on record.

  • $131,684 — penalty dated 2026-04-23
  • Medicare payment denial — starting 2026-05-21 for 8 days
  • Medicare payment denial — starting 2025-06-13 for 26 days

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

Part of a chain

This home belongs to ATIED ASSOCIATES — 12 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 1 of 51.8-0.8 vs chain
Health inspection 3 of 52.2+0.8 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 1 of 53.2-2.2 vs chain
The other 11 homes this chain runs (chain average 1.8★, 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 / managerTypeRoleShareSince
RAY, SHERWINIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF50%since 01/01/2015
ROTHNER, ERICIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 01/11/2025
ARONIN, DAVIDIndividualCORPORATE DIRECTORsince 01/01/2015
EXTENDED CARE CLINICAL LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015
EXTENDED CARE CONSULTING LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015
ROTH & CO, LLPOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015
DIXON, WILLIAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2015
SPRINGER, JERRIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/01/2015
ATIED ASSOCIATES LLCOrganizationADP OF THE SNFsince 12/15/2024

CMS files one row per role, so the 17 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$5.3M
Net patient revenuemost recent cost report
-10.4%
Operating marginrevenue minus expenses
$444K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 10%Other / private 9%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $444K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$297per resident / day
operating cost
$9,040per month
≈ monthly operating cost
$269per 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 145294. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-11, 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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