Evercare of Jerseyville
410 Fletcher St, Jerseyville, IL 62052 · For profit - Limited Liability company · 98 certified beds · (618) 498-6427 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has abuse, neglect, or exploitation citations (F0600, F0607) — most recent Dec 2025
- 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
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (42) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $143,408 in federal fines (most recent 2025-12-14)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 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 held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 33.7% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.2% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.3% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 57.9% | 54.2% | 6.5% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.2% | 3.1% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 34.7% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 36.7% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 73.3% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 6.6% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.1% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 41.9% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.8% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 19.4% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 24.7% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 14.4% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.63 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 4.08 | 2.22 | 1.80 | worse |
‡ 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.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not 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 worsened | not 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 hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 98 beds and averages 62.4 residents a day — about 64% occupied, or roughly 36 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 2.89 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.49 hrs/resident/day on weekends vs 3.05 on weekdays — 19% thinner on weekends. RN hours go from 0.25 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
42 citations, most serious first. The 15 most serious are shown; the remaining 27 are one tap away and print in full.
- Immediate jeopardy · L2025-12-14 · tag F0607 — failed to have anti-abuse policies — widespreadDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 its abuse and resident background check policies by failing to screen for potentially abusive residents during the admission process, failing to report and track residents qualifying criminal offenses, failing to ensure a risk assessment was completed, and failing to implement protective measures to prevent abuse for 1 of 3 (R54) residents reviewed for abuse in the sample of 35. This failure resulted an Immediate Jeopardy when R62 was admitted to the facility on [DATE] without appropriate screening, referrals and interventions for criminal convictions and proceeded to sexually abuse R54. This has the potential to affect all 55 residents who reside in the facility. The Immediate Jeopardy began on 9/26/25 when R62 was admitted to the facility. R62's Criminal History record, dated 9/29/25, documented R62 has a history of criminal convictions including retail theft, obstructing justice, deceptive practice, battery, and aggravated battery with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-12-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 observation, record review, and interview, the facility failed to ensure 1 of 3 (R24) resident's call light in reach in a sample of 35. This failure resulted in R24 unable to call for help for over 2 hours. This also resulted in R24 sitting in urine, feeling angry, embarrassed, unwanted, depressed and a burden.Findings include:R24's Care Plan, dated 3/25/2025, documents R24 has an ADL (activities of daily living) self-care performance deficit r/t (related to) Dementia, Impaired balance, Limited Mobility, Limited ROM (range of motion), Stroke with left sided weakness. Interventions Encourage the resident to use bell to call for assistance. R24 is at risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs. Interventions The resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach to right side of resident.R24's Minimum Data Set (MDS),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-12-14 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent physical abuse of a resident from another resident with a known criminal history for 1 of 4 residents (R54) reviewed for abuse in the sample of 35. This failure resulted in R62 exposing his genitals to R54 and R62 then grabbed R54's breast. A reasonable person would expect to be safe in their home and would experience fear/anxiety, humiliation, and anger if physically and sexually abused. Findings Include:R54's Medical Diagnosis sheet, print date of 12/9/25, documented R54 has diagnoses including Parkinsonism, dementia, osteoporosis, atherosclerotic heart disease, polyneuropathy, and cognitive communication deficit. R54's MDS (Minimum Data Set), dated 9/17/25, documented R54 is severely cognitively impaired and dependent on staff for ADLS (activities of daily living) and mobility. R54's care plan, undated, documented R54 has little, or no activity involvement related to immobility, physical limitations, due to Parkinson's and dementia. R54'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.
- Actual harm · Gcited before2025-12-14 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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 timely and complete incontinent care for 4 of 4 (R7, R8, R22, R24,) residents in a sample of 35. This failure resulted in R24 feeling angry, embarrassed, unwanted, depressed and a burden. Findings include:1. R24's Care Plan, dated 3/25/2025, documents that the resident has bladder incontinence r/t (related to) Confusion, Dementia, Impaired Mobility, Poor toileting habits total assist with transfers per Hoyer lift. It also documents interventions: Brief Use: The resident uses disposable briefs. Change every 2 hours and prn (as needed). Clean peri-area with each incontinence episode. Incontinent: Check every 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. R24's Minimum Data Set (MDS), dated [DATE], documents that resident is rarely/never understood, always incontinent of bowel and bladder and dependent on staff for activities of daily living. R24'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.
- Actual harm · Gcited before2023-09-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide and implement interventions to prevent resident falls for 4 of 4 residents (R11, R19, R29, R32) reviewed for resident safety in the sample of 27. This failure resulted in R32 transported to the hospital for a facial laceration with sutures and a fractured humerus on one incident, and a fractured hip with surgery on another incident. The Findings Include: 1. R32's Face Sheet, undated, documents R32 was admitted to the facility on [DATE]. R32's medical diagnosis include Major depressive disorder, Dementia with behavioral disturbances, Anxiety Psychotic disorder, Hypertension, (HTN), Gastroesophageal reflux disease, (GERD), and Insomnia. The facility's Fall Analysis Log, undated, documents, R32 had a fall on 7/26/23, 7/27/23, and 8/28/23. R32's Fall Risk was entered into the Care Plan on 9/5/23 after R32 had several falls. There were no interventions added after each fall. R32's Care Plan, dated 9/5/23, documents, Falls: R32 admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-06-30 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
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 meals were being served at regular times and without long waits. This has the potential to affect all 58 residents living in the facility. Findings include: On 6/24/2026 at 9:30 AM, in the main dining room area there is a bulletin board that documents scheduled mealtimes for breakfast at 7:30 AM, lunch at 11:30 AM, and dinner at 5:00 PM. On 6/24/2026 at 9:39 AM, V1, Administrator stated lunch was served at 11:30 AM, daily. On 6/24/2026 at 12:05 PM, V34 was the only staff in the kitchen. The dining room is full of residents sitting at tables waiting for their lunch. On 6/24/2026 at 12:10 PM, all food was placed on the steam table and V34, Dietary Manager took the temperatures. Residents were waiting in the dining room to be served lunch. On 6/24/2026 during the lunch service the last resident was served at 1:18 PM, for a total of one hour and 48 minutes lunch service for 59 residents. R31's Minimum Data Set (MDS) dated [DATE] document…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-06-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination for 4 of 25 residents (R11, R30-R32) reviewed for food temperatures in the sample of 32. Findings inclue:On 6/25/2026 at 11:30 AM, V34, Dietary Manager was placing items from the oven into the steam table. V34, took the temperatures and recorded them in her Food logbook with no issues. No additional food temperatures were taken during the entire meal service, which lasted one hour and 48 minutes for the food service for 59 residents. During the lunch service after the last person had been served on 6/25/2026 from 1:01 PM-1:19 PM, R11, R30, R31 and R32 were all served the corn. On 6/25/2026 at 1:19 PM, the temperatures were taken with a calibrated metal thermometer, and the following items were not above 135 degrees Fahrenheit. The corn was 103.0 F, the mechanical stew registered at 104.0F. R31's Minimum Data Set (MDS) dated [DATE] document R31 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately 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 report a change in condition to a resident's family/responsible party for one (R5) of 3 residents sampled for notification in a sample of 33. Findings include: R5's Undated Face Sheet, documents he was initially admitted to the facility on [DATE].R5's Quarterly Minimum Data Set (MDS), dated [DATE] R5 was cognitively intact. R5's Physician's Order Sheet (POS) dated 3/28/2026 documents a new physician's order for Ertapenem Sodium injection intravenous (IV) use 1 gram one time for UTI/proteus in urine until 4/4/2026. No documentation R5's family or responsible party was notified. R5's Medication Administration Record (MAR) dated 3/29/2026 staff documents 9 in the box for the Ertapenem IV medication. R5's Nursing Note, dated 3/29/2026 at 10:58 AM documents this writer attempted to place an IV in resident's right wrist, was unsuccessful. Resident stated he would only allow this writer to attempt one time. DON (Director of Nurses) notified and will attempt 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.
- Potential for harm · D2026-06-30 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide discharge planning and a letter stating when Medicare days would be exhausted for one (R4) of 3 residents at the facility sampled for resident's discharge rights in a sample of 33. Findings include: R4's Undated Face Sheet documents she was initially admitted to the facility on [DATE]. Review of R4's Electronic Medical Record including Progress Notes dated 2/2026 through 3/2026 there was no documentation of discharge planning. On 6/23/2026 at 1:00 PM V4, Social Services Director stated she started as the facility social worker in March 2026 so she wasn't working her when R4 was initially admitted to the facility on [DATE]. V4 stated after a resident is admitted to the facility, they have an initial care plan meeting where discharge planning is discussed which is 72 hours after admission and then they have Medicare meetings every Monday but she just got access to the web link for those Monday Medicare meetings so she has attending 1 or 2 of them.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-30 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure Residents' allergies were being followed/honored for 1 of 3 residents (R3) reviewed for allergies in the sample of 31. This failure resulted in (R3) being exposed to bleach which was listed as an allergy for her, and being sent to the hospital. Findings include:A. R3's Physician Order Sheet for June 2024 documents a diagnosis of burns involving 20-29% of body surface with 20-29% third degree burns; essential (primary) hypertension; type 2 diabetes mellitus with unspecified complications; personality disorder, anemia; unspecified post-traumatic stress disorders, hypothyroidism. R3's Minimum Data Set (MDS) dated [DATE] documents she is cognitively intact for decision making of activities of daily living. She has no impairment on her upper or lower extremities. She uses a wheelchair and needs assistance with most ADL's. (activities of daily living). R3's Medical Records under allergies document R3 was allergic to bleach. R3's Care Plan does not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-12-14 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and observation, the facility failed to post the facility staffing data daily, reviewed for staffing in the sample of 35. This failure has the potential to affect all 55 residents residing in the facility. The findings include: On 12/8/25 at 8:00 AM and upon entrance to the facility, there was no posting of daily staffing seen on the boards or walls in the front lobby or in the halls. On 12/9/25 at 4:30 PM, there was still no posting of the facility daily staffing seen.On 12/10/25 at 8:00 AM, there was still no posting of the facility daily staffing seen.On 12/10/25 at 8:30 AM, V3, Assistant Director of Nursing (ADON), stated, I am the one who posts the daily staffing, and I have not done it this week. I usually post it either by the front door or by the Director of Nursing's (DON's) office.On 12/10/25 at 3:45 PM, V1, Administrator, stated, I don't think we have a policy on posting of staffing. I would expect the staff to be posting the staffing daily.On 12/10/25 at 3:47 PM, V28, Regional Director of Operations, stated, We would follow the State and Federal…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-14 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 medication, label and discard expired medication. This has the potential to affect all 55 residents residing in the facility.Findings include:On 12/8/2025 at 8:59 AM the facility medication room was inspected. In the refrigerator located in inside the medication room observed: 1. 3 boxes of Influenza with expiration date 6/2025. 2. 1 box of open and partially used multidose vial of Aplisol with handwritten date of 11/1/25. The Tuberculin (Aplisol) Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. On 12/9/2025 at 3:24 PM V29, Licensed Practical Nurse, stated the facility did administer influenza. V29 stated the influenza vaccine is stored in the refrigerator in the medication room. V29 verified the influenza vaccine was expired. V29 stated the medication should not be in the refrigerator and should have been destroyed. V29 verified the Aplisol multidose vial 11/1/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to dispose of expired food items, to wear proper hair nets when required, and to practice proper infection control including using clean utensils and performing hand hygiene, reviewed for the storage, preparation, and sanitary serving of food in the sample of 35. These failures have the potential to affect all 55 residents in the facility.The findings include: On 12/08/25 at 8:40 AM, Initial Kitchen Observation completed with V4, Dietary Manager, who has a valid food service certificate. Upon entrance to the kitchen, V4 was seen in the kitchen without a hair net on with short hair, a mustache and a beard.On 12/8/25 at 8:42 AM, V6, Dietary Aide, was seen working in kitchen with a hair net on and large amounts of hair coming out from the front, sides, and back of her hair net. On 12/8/25 at 8:44 AM, V7, Cook, seen in kitchen working with the food, serving the food to residents at the warming station, with a hair net on and large amounts of hair coming out of front, sides, and back of the hair net.The Refrigerator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-14 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to perform hand hygiene and to don appropriate Personal Protective Equipment (PPE) for 4 of 24 residents (R7, R8, R27, R54), and the laundry staff failed to don PPE while laundering isolation linen, all was reviewed for infection control in the sample of 35. These failures have the potential to affect all 55 residents residing in the facility.The findings include: 1. On 12/9/25 at 8:09 AM, V14, Certified Nursing Assistant (CNA), was seen feeding two residents while sitting between them, no hand hygiene seen as she would turn and feed R54 on her right side, then with no hand hygiene, would turn and feed R27 on her left side. V14 was seen assisting other residents across the table with their drinks while feeding R54 and R27 with no hand hygiene seen done before, during, or after assistance given. On 12/11/25 at 10:55 AM, V2, Director of Nursing (DON), stated, I would expect the staff to do hand hygiene when assisting the residents in feeding and should not be feeding one resident after another without doing hand…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-12-14 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, and record review, the facility failed to ensure the continuing competence of Certified Nursing Assistants (CNAs), by providing 12 hours of education and/or training per year, including dementia management training and resident abuse prevention training, reviewed for required training for CNAs in the sample of 35. This failure has the potential to affect all 55 residents residing in the facility.The findings include:On 12/10/25 at 8:35 AM, V3, Assistant Director of Nursing (ADON), stated, When we hire a new CNA, they always have a license already. They will go through orientation with V18, Medical Records/CNA. Then they will have at least 3 days of floor training with a peer. If that person needs more training, we will give them more days. We do monthly in-services that are scheduled, and each employee must do that in-service before their next day of work. We also do competencies yearly for each staff member and then PRN (as needed) if someone is lacking in a certain task. When asked to see any CNAs 12-hour training, V3 stated, (V1, Administrator) has that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 27 citations
- Potential for harm · E2025-12-14 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to answer call lights timely for 4 of 24 residents (R2, R6, R12 and R30) reviewed for call lights in the sample of 35. Findings include:1. On 12/9/2025 at 10:30AM during resident group meeting. R2, R6, R12 and R30 all stated call lights are not answered timely.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. R6's MDS dated [DATE] documents R6 is cognitively intact.R12's MDS dated [DATE] documents R12 is cognitively intact.R30's MDS dated [DATE] documents R30 is cognitively intact.Resident council minutes dated 12/2/2025 documents residents feel that call lights are not being answered in a timely manner.Resident council minutes dated 10/6/2025 documents call lights are not being answered in a timely manner.Resident council minutes dated 8/4/2025 documents call lights are taking too long to be answered.Resident council minutes dated 6/2/2025 documents call lights are takin too long to be answered.On 12/10/2025 at 9:25AM V21…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-12-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 as identified in resident care plans for 4 of 9 residents (R1, R9, R33 and R53) reviewed for accidents in the sample of 35. Findings include: 1. On 2/8/2025 at 8:50 AM recliner in R53's room does not have mat in the seat. On 2/10/2025 3:15PM R53's recliner in room does not have mat in the seat as identified as intervention in care plan. R53's care plan dated 10/29/2025, documents R53 is at risk for fall, refuses wheelchair handles on wheelchair, related to stroke with right sided weakness, confusion, gait/balance problems and incontinence poor communication/comprehension, Unaware of safety needs. R53's care plan documents the following intervention for fall: 9/25/2025 place Dycem in recliner chair, follow facility fall protocol. R53's care plan documents that R53 has had 5 falls since 7/24/2025. R53's Minimum Data Set (MDS) dated [DATE] document R53 has severe cognitive impairment. R53's MDS documents R53…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-14 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure 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 interview and record review, the facility failed to identify and monitor the use of a lap tray for 2 of 2 (R27, R54) residents reviewed for restraints in a sample of 35.Findings include: 1. R27's admission Record, print date 12/9/2025, document R27 has diagnosis including Vascular Dementia, Anxiety, and Depression. R27's Care Plan does not address R27's lap tray and restraint. R27's Minimum Data Set, dated [DATE], documents that R27 is cognitively impaired, dependent on staff for care and does not use restraints. R27's Physician Orders do not document an order for a lap tray or a restraint. On 12/8/2025 at 9:41 AM observed R27 sitting in room facing television. R27 sitting in reclining wheelchair with lap tray attached and secured across R27's lap. R27 was not able to remove lap tray upon request. 12/9/2025 at 10:00 AM observed R27 sitting in reclining wheelchair with lap tray attached and secured across R27's lap. On 12/10/2025 at 8:24 AM observed R27 sitting in reclining wheelchair with lap tray…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide eating assistance for 1 of 24 residents (R9) reviewed for assistance with eating in the sample of 35. On 12/09/2025 at 8:00AM R9 observed sitting in wheelchair in dining room eating cooked cereal out of bowl. Glass of orange juice, and glass of water sitting in front of R9. Plate with scrambled eggs and biscuit with jelly also in table. At 8:47AM R9 observed eating scrambled eggs with his hands. R9 ate 100% of cooked cereal and drank glass of water. At 8:55AM R9 drank 100% of orange juice. At 8:58AM R9 turned plate clockwise with biscuit and jelly and scrambled eggs., touched eggs with hands. At 9:03AM V34, Certified Nursing Assistant (CNA) approached table and ask R9 if would like more to drink, and requests coffee. V34 did not provide R9 touch assistance or encouragement to eat his scrambled eggs or biscuit. R9 had 50% of his scrambled eggs and 1/2 of biscuit remaining on his plate. R9's dietary note dated 11/11/2025 at 13:45…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide feeding assistance for a resident with weight loss for 1 of 24 residents (R9) reviewed for nutritional status in the sample of 35.On 12/09/2025 at 8:00AM R9 observed sitting in wheelchair in dining room eating cooked cereal out of bowl. Glass of orange juice, and glass of water sitting in front of R9. Plate with scrambled eggs and biscuit with jelly also in table. 8:47AM R9 observed eating scrambled eggs with his hands. R9 ate 100% of cooked cereal and drank glass of water. At 8:55AM R9 drank 100% of orange juice. At 8:58AM R9 turned plate clockwise with biscuit and jelly and scrambled eggs., touched eggs with hands. At 9:03AM V34, Certified Nursing Assistant (CNA) approached table and ask R9 if would like more to drink, and requests coffee. V34 did not provide R9 touch assistance or encouragement to eat his scrambled eggs or biscuit. R9 had 50% of his scrambled eggs and 1/2 of biscuit remaining on his plate. R9's dietary note dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop/implement interventions for 1 of 3 residents reviewed for pressure ulcers in the sample of 4. Findings include: R2's face sheet documents an admission date of 4/27/2025. Diagnosis include Hypertensive Heart Disease with Heart Failure, Human Immunodeficiency Virus, Chronic Obstructive Pulmonary Disease, Acute Myocardial Infarction, Cerebral Infarction. On 6/5/2025 at 8:15AM V3, Assistant Director of Nursing, ADON, stated R2 does not have any skin issues. On 6/5/2025 at 8:30AM V3 stated, We just did a skin check on R2 and she does have a new area to her left buttock. We just found it this morning. She recently came back from the hospital. I talked to the nurse who did R2's admission assessment and he denied any skin issues. She was in the hospital quite a while. On 6/5/2025 at 9:30AM V3, Assistant Director of Nursing, ADON, and V4, Licensed Practical Nurse, LPN, performed skin check to R2. Dime size open reddened area noted to left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-29 · tag F0727 — failed to provide required RN coverage — widespreadHave 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 — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to employ a Registered Nurse as Director of Nursing (DON). This failure has the potential to affect all 41 residents residing in the facility. The findings include: On 8/26/24 at 8:37 AM, when asked who the DON was, V1, Administrator, stated, We currently do not have a DON. On 8/27/24 at 3:00 PM, V1 stated, We have been without a DON for a little over a month. We are running an ad and refreshing the ad weekly. I have interviewed one person so far. On 8/28/24 at 8:13 AM, V2, Registered Nurse (RN), stated, We have not had a DON for a couple of months. If I had any nursing issues, I would go to the Minimum Data Set (MDS) Nurse (V11). I know she is doing the nursing schedule and some of the other duties of the DON. On 8/28/24 at 8:15 AM, V1 stated, Our DON's last day was 6/28/24. Between myself and (V11, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Nurse), we are covering the duties of the DON. I do things that don't require a nursing license and she does the rest. On 8/28/24 at 9:40 AM, V11 stated, I am doing most of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-08-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation, and record review, the facility failed to serve food in a sanitary manner, label, and date open food, ensure equipment is clean, and perform hand hygiene before donning gloves to prevent food borne illness. This has the potential to affect all 41 residents living in the facility. Finding include: 1. On 8/26/24 at 8:45 AM, the kitchen was entered. The stand-up freezer had a box of pre-made omelets. The bag was not sealed, and the omelets had freezer burn. The walk-in refrigerator has a storage container of red liquid that was not labeled or dated, 2 opened paper cartons of tomato juice that was dated 7/18, an opened package of hot dogs dated 8/22/24 no expiration date, a plastic container of what appeared to be mandarin oranges that is not labeled or dated with the lid covered in a thick liquid substance, a stainless steel container of tomatoes that was covered in foil that was not labeled or dated, 4 storage bags that had meat that were not dated or labeled. On 8/26/24 at 9:00 AM, V19, Dietary Manager, stated that everything should be labeled and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-29 · tag F0882 — widespreadDesignate 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 provide a qualified individual responsible for the Infection Prevention and Control Program. This failure has the potential to affect all 41 residents living in the facility. The findings include: On 8/28/24 at 8:15 AM, V1, Administrator, stated, Our DON's (Director of Nursing) last day was 6/28/24. Between myself and (V11, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Nurse), we are covering the duties of the DON, including infection control. I do things that don't require a nursing license and she does the rest. I am the certified Infection Preventionist, and I work with (V11) to get things done. On 8/28/24 at 9:40 AM, V11, MDS Nurse, stated ,I am doing most of the duties of the DON. I investigate all the incidents that happen, do the scheduling for both the CNAs and the Nurses, and keep up with the infection log. (V1) does a lot of the other duties. On 8/28/24 at 10:40 AM, V11 stated, I do not have an Infection Preventionist Certification, (V1) has one. The Pharmacy sends me a report of all residents on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 interview, observation, and record review, the facility failed to provide incontinent care to prevent Urinary Tract Infections for 5 of 6 residents (R4, R5, R14, R26, R30) reviewed for incontinent care in the sample of 34. Findings include: 1. On 8/27/24 from 8:50 AM until 12:12 PM, staff did not assist R30 with toileting based on 15 minute or less checks. On 8/27/24 at 12:12 PM, R30 propelled herself into the community bathroom. R30 waited in the bathroom with the door open. At 12:16 PM, V14, Certified Nurse Aide (CNA), entered the bathroom and questioned R30 what she was doing. R30 stated, I gotta go. V14 stated that she would get some help and left the room. V14 came back and began to put the partial mechanical lift sling on R30. V14 began to prepare the partial mechanical lift to use on R30. V9, CNA, entered the bathroom and stated, We have to take her to room A-7. R30 and the partial mechanical lift were taken down to A-7. R30 was transferred to the toilet and her incontinent brief was removed. V14…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-29 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
4. On 8/27/2024 at 8:50AM during incontinent care V8, CNA gloved when providing incontinent care to R14. After providing incontinent care to V8 and while wearing the same gloves, V8 put on protective cream on R14's buttocks and place a new incontinent brief on R14 without changing gloves. V8 then put on R14's TED (Thrombo-Embolic Deterrent ) hose, put clothes on and placed a mechanical lift sling under R14 while wearing these same gloves. Based on interview, observation, and record review, the facility failed to perform hand hygiene, wear personal protective gowns, disinfect multi-use equipment, and post isolation signs for 6 of 16 residents (R4, R5, R14, R26, R30, R38) reviewed for infection control in the sample of 34. Findings include: 1. On 8/26/24 at 11:54 AM, V3, Licensed Practical Nurse while preparing R4's medications donned and doffed gloves 6 times without hand hygiene before or after. On 08/26/24 at 12:01 PM, R4's room had no signage indicating that Enhanced Barrier Precautions need to be used. V3, Licensed Practical Nurse (LPN), entered the room to give medications…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to report an alleged allegation of abuse to Illinois Department of Public Health for 1 of 1 resident (R35) reviewed for reporting of alleged abuse in a sample of 34. Findings include: R35 was admitted to the facility on [DATE] with diagnosis of, in part, hypertension, arthritis, osteoarthritis, spinal stenosis, chronic heart failure. R35's Minimum Data Set (MDS) dated [DATE] documents R35 is cognitively intact. On 08/26/24 at 9:40 AM, R35 stated V15, prior director of nursing (DON), kicked the back of her legs causing her to fall and become a full body mechanical lift and V15 has threatened to do it again to her. R35 stated she does not remember how long ago this took place, but she reported it to her doctor and other staff members at the facility. R35 stated V15 does not provide care to her any longer but still works at the facility as needed (PRN). Record review of R35's chart shows no reported incident took place. On 08/27/24 at 8:33…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (R35) reviewed for abuse investigations in a sample of 34. Findings include: R35 was admitted to the facility on [DATE] with diagnosis of, in part, hypertension, arthritis, osteoarthritis, spinal stenosis, chronic heart failure. R35's Minimum Data Set (MDS) dated [DATE] documents R35 is cognitively intact. On 08/26/24 at 9:40 AM, R35 stated V15, prior director of nursing (DON), kicked the back of her legs causing her to fall and become a full body mechanical lift and V15 has threatened to do it again to her. R35 stated she does not remember how long ago this took place, but she reported it to her doctor and other staff members at the facility. R35 stated V15 does not provide care to her any longer but still works at the facility as needed (PRN). Record review of R35's chart shows no reported incident took place. On 08/27/24 at 8:33 AM, after review of the facility'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.
- Potential for harm · Dcited before2024-08-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow plan of care and provide supplements as ordered to maintain acceptable parameters of nutrition for 1 of 4 residents (R1) reviewed for nutrition in the sample of 34. Findings include: 1. Registered Dietitian's (RD) quarterly review, dated 6/24/2024, documents Height (HT) 67 inches, weight (wt) 146 # (pounds). Currently showing a gradual weight loss x 6 months; 12/23 154, 3/24 152, 5/24 147. The Review documents R1 remains on regular diet with cut up meat, super cereal at breakfast. intakes at meals around 75% with occasional 100's noted and fluids 240-480cc/meal. Notes documents suggest to please consider adding ice cream to lunch/supper meals for added calories with varied intakes and weight loss reported. Monitor and refer to RD as needed. R1's monthly weight for July 2024 documents weight of 141.8 # August monthly weight documents a weight of 137.2. R1's Physician Order (PO) dated 7/26/2024 documents add ice cream to lunch and supper. R1's Care Plan dated 6/19/2024 documents at risk for weight loss…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to check the residual from a Gastrostomy tube (G-tube) before administering a water flush and medications and turn off the feeding pump while R4 was lying flat for 1 of 1 resident (R4) reviewed for tube feeding in the sample of 34. Findings include: On 08/26/24 at 12:01 PM, V3, Licensed Practical Nurse (LPN), entered the room to give medications and a water flush through R4's G-tube. V3 did not check for residual before giving R4 65 milliliters of water. V3 then gave the medication and another flush of 65 milliliters of water. On 8/27/24 at 10:15 AM, V10 Certified Nurse's aide (CNA) lowered the head of the bed to flat to prepare for incontinent care. R4's tube feeding pump was running. V10 and V8, CNA, performed the incontinent care with the feeding pump running. On 8/27/24 at 10:19 AM, V10 was questioned why he lowered the head of bed with the feeding pump running, V10 stated that he was unaware that the feeding pump should be off if the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0810 — isolatedProvide special eating equipment and utensils for residents who need them and appropriate assistance.
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 the facility failed to provide assistive device or adaptive eating equipment resulting in R22's inability to use eating utensils effectively and eating with hands for 1 of 16 residents (R22) reviewed for assistive devices/eating equipment/utensils in the sample of 34. Findings include: 1. On 8/26/2024 at 11:40AM R22 was eating pork fritter, scalloped potatoes, green beans, and pears. R22 was using a regular spoon and used his left had to scoop food on to his spoon, then with his left-hand placed on spoon and places in his mouth. On 8/27/2024 at 11:44AM R22's plate contained diced potatoes, peas, roll, and turkey with gravy. R22 used left hand to push food on spoon and placed food in mouth. On 8/27/2024 at 12:01PM R22 observed picking peas up off the table that had dropped from spoon in his mouth and observed picking peas up off his bib and placing in his mouth. R22's Care Plan, dated 5/6/2024 documents self-care deficit-needs supervision and or assist to complete quality care and/…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-28 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 interview, observation and record review, the facility failed to maintain the medication refrigerator at the proper temperature. The failure has the potential to affect all 35 people living in the facility. Findings include: On 9/26/23 at 10:15 AM, the medication room was entered with V2, Director of Nurses, (DON). The medication refrigerator had a thermometer in it, and it was reading 25 degrees. There was a temperature log on the refrigerator door. The last date entered was 9/26/23 and it reads 24 degrees. There are 3 epinephrine pens. There are 8 multi-use vials of Tubersol. There are 7 boxes with 10 single use injections of Influenza vaccine. V2 stated, that all 3 of these medications are stock medications. On 9/27/23 at 10:15 AM, V2, stated, The midnight nurse is supposed to check and log the medication refrigerator temperature and if it is wrong then the nurse is expected to adjust the refrigerator and recheck it. The Refrigerator Temperature Log, dated September 2023, documents 3 days of 24 degrees, 1 day of 26 degrees and 3 days of 28 degrees. This Log fails 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.
- Potential for harm · Fcited before2023-09-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, observation and record review, the facility failed to store food to prevent contamination and food borne illness, ensure the dishwasher, refrigerator and freezer are operating properly and ensure the refrigerators, freezers, equipment, and walls are clean. This failure has the potential to affect all 35 residents living in the facility. Findings include: On 9/27/23 at 10:30 AM, the kitchen was entered and toured. V4, Dietary Manager is present for the tour. The dry storage room had a box containing 7 boxes of oatmeal pies on the floor and a plastic storage container containing 20-pound bag of powder sugar which had a measuring cup in it with the handle in the powder sugar. There is a non-commercial refrigerator has a sign on it that documented, the refrigerator is for resident food only, not for employee use. V4 stated the facility has no residents that have families or friends that bring food in for the residents. The freezer portion of the refrigerator had a case of magic cups for the residents, 2 packages of eye of round steaks with freezer burn, 2 cartons of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-28 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a Licensed Nursing Home Administrator as V1's temporary license expired on 5/2022 and has not been working with a current license since. This has the potential to affect all 35 residents in the facility. The Findings Include: On [DATE] at 1:38 PM, V1, Administrator, stated, I was working under a temporary license, and it expired in May of 2022. I took the Federal test and passed it, but I failed the state test. I am working under the Regional Director of Operations, who is in the facility once a month. I am aware that I am listed as the Licensed Administrator for this facility. On [DATE] at 12:45 PM, V1, stated, We really don't have a policy that states, the Administrator must be licensed. We have a Staffing Policy that states, Licensed Nurses are required to be licensed by the State in which they are practicing. Copies of the current licensees shall be displayed in the facility. The only thing that I have is my job description that tells me I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-28 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to disclose Quality Assurance and Performance Improvement, (QAPI) documents to verify the facility is actively participating in a QAPI program. This failure has the potential to affect all 35 residents living in the facility. Findings include: On 09/28/23 at 10:06 AM, V1, Administrator, stated the facility does have Quality Assurance Assessment, (QAA) /QAPI meeting minutes and notes. The QAA/ QAPI meeting minutes / notes were requested for review. V1 refused to provide the documents. The facility failed to provide QAA /QAPI meeting minutes and notes. The Resident Census and Conditions of Residents, CMS 672, dated 9/18/23, documents the facility has 35 residents living in the facility.
- Potential for harm · F2023-09-28 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors to problems. This failure has the potential to affect all 35 residents living in the facility. Findings include: On 09/28/23 at 10:06 AM, V1, Administrator, stated the facility has meeting daily and each day of the week has a high-risk topic, which is discussed at that time. V1 said, We evaluate the problem and see if we can put in interventions or review the resident to figure out what the problem is and to make it better. The daily meeting information is evaluated, weekly to see if it has been resolved. If the problem has not been resolved, it will go to the quarterly meeting. V1 stated the facility will identify a problem and they will work on it, but there is no formal plan or program they use to correct or identify problems. V1 stated, (V12 Medical Director) is a part of the QAA committee. (V12) has not participated in the meetings in person or via phone for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-28 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to have the Medical Director attend meetings and have input into the Quality Assurance (QA) meetings and to hold quarterly meetings. This failure has the potential to affect all 35 residents living in the facility. Findings include: On 09/28/23 at 10:06 AM, V1 stated, (V12 Medical Director) is a part of the QA committee. (V12) has not participated in the meetings in person or via phone for the last 2 meetings. (V12) gets the information that we talked about in the quarterly meeting when he comes in and makes his rounds. (V12) does bring problems to us but we do not QAPI (Quality Assurance and Performance Improvement) them we just fix them. On 09/28/23 at 11:25 AM, V1 stated the facility did not hold a July 2023 QA meeting. The QA meeting signature page, dated 1/10/23 and 9/7/23, fails to document V12's signature of attendance. The QA meeting signature page, dated 4/6/23, documents V12 attended over the phone. The Quality Assurance Plan, undated, documents, Quality Assurance Committee will conduct Quarterly meetings (at a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-28 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to maintain a program to ensure water safety. This failure has the potential to affect all 35 residents living in the facility. Findings include: On 9/27/23 at 11:40 AM, V1, Administrator, stated the facilities maintenance worker is on vacation this week. V1 was asked to review the water policy to see how maintenance manages the empty rooms and the water temperature logs. V1 stated she would look for that information. On 9/27/23 at 1:00 PM, V1 was questioned if she had any water information available for review. V1 stated, It is on its way. V1 was questioned as to why the information was not in the facility. V1 stated, My computer crashed, and it is slowly coming back up. On 9/27/23 at 3:30 PM, V1 stated, she has the water information. V1 presented the water temperature policy and 3 log sheets. It again was explained what documents were being requested, V1 stated, I will have to look. On 0/28/23 at 8:30 AM, V1 present a policy on how to handle the facilities water system. V1 was asked for the information to prove the measures…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-28 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide Alzheimer's Dementia training for nursing staff. Findings include: On 9/26/23 at 10:00 AM, V2, Director of Nurses, (DON), stated, When Covid hit there was CMS, (Central Management System), training that everyone had to take and it covered a little bit of dementia and that is the only training they got. 1. V9, Certified Nurse Aide, (CNA), In-Service Record documents, V9's hire date was 10/28/19. The record fails to document, any Dementia training. 2. V3, CNA, In-Service Record documents, V3's hire date was 08/15/09. The record fails to document, any Dementia training. 3. V14, CNA, In-Service Record documents, V14's hire date was 11/16/21. The record fails to document, any Dementia training. 4. V7, CNA, In-Service Record documents, V7's hire date was 7/22/22. The record fails to document, any Dementia training. 5. V16, CNA, In-Service Record documents, V16's hire date was 8/8/22. The record fails to document, Dementia training. On 9/28/23 at 9:15 AM, V2, Director of Nurses, stated she did not know that Alzheimer'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.
- Potential for harm · Ecited before2023-09-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 and timely incontinent care for 3 residents (R21, R27 and R32) of 4 residents reviewed for incontinence in the sample of 27. The Findings include: 1. On 9/26/2023 at 11:34 AM R21 ambulating to dining room V8, Certified Nursing Assistant, (CNA), assisting by holding onto gait belt around R21's waist. R21's pants are visibly wet. R21 seated in chair in the dining room. On 09/26/23 at 12:28 PM, V9, CNA assisted R21 from chair to standing in dining room with use of a gait belt. V9 assisted R21 from dining room to his room. R21's pants are visibly soaked. V9 sat R21 on the toilet and removed adult diaper that was saturated with urine. R21 stood up in bathroom holding on to his walker. V9 CNA then sprayed no rinse peri wash on wash cloth. V9 then swiped across R21's buttocks with washcloth wash. V9 used another washcloth with no rinse peri wash and wiped R21's peri area. V9 did not cleanse R21's scrotum or penis. V9 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-08-29 · tag F0574 — widespreadThe resident has the right to receive notices in a format and a language he or she understands.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to post ombudsman contact information. This has the potential to affect all 41 residents at the facility. Findings include: On 8/27/2024 at 1:00PM, R2, R7, R20, and R15 all stated they were not aware of ombudsman contact information being posted. On 08/27/24 01:16 PM surveyor was unable to locate ombudsman contact information within the facility. On 8/28/2024 at 12:16PM V1, Administrator, stated the facility does not have a policy regarding posting of ombudsman information. V1 stated she would expect the information to be posted. V1 stated the facility does not have a specific policy, but the facility does follow Illinois Department of Public Health (IDPH) guidelines. The facility's Long-Term Care Application for Medicare and Medicaid, CMS 671 dated 8/26/2024 documents a census of 41 residents.
- No harm found · C2024-08-29 · tag F0577 — widespreadAllow residents to easily view the nursing home's survey results and communicate with advocate agencies.
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 post survey results. This failure has the potential to affect all 41 residents residing at the facility. Finding include: 1. On 8/27/2024 at 1:00PM during resident council R2, R7, R20 and R15 all stated unaware of survey results being available. Throughout the survey, the survey results of the last standard survey were not available. On 08/27/24 at 1:16 PM V1, Administrator stated the results of the state inspection are not available to read. V1 stated I have them. On 8/29/2024 at 8:10AM, V1, Administrator stated the facility does not have a policy in regard to posting survey results. V1 stated she would expect the information to be posted. V1 stated the facility follows Illinois Department of Public Health (IDPH) guidelines. The Illinois Long-Term care ombudsman program residents rights for people in long term care facilities dated revised 11/18 documents your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life, rights to dignity and respect.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$143,408 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $82,090 — penalty dated 2025-12-14
- $61,318 — penalty dated 2023-09-28
- Medicare payment denial — starting 2023-10-20 for 32 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 EVERCARE SKILLED NURSING — 8 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.1 | -0.1 vs chain |
| Health inspection | 1 of 5 | 1.6 | -0.6 vs chain |
| Staffing | 1 of 5 | 1.0 | ≈ chain avg |
| Quality measures | 1 of 5 | 1.9 | -0.9 vs chain |
The other 7 homes this chain runs (chain average 1.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ECAPITAL HEALTHCARE CORP | Organization | 5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2024 |
| ROSENBLATT, YEHUDA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| EU SNF HOLDINGS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2024 |
| HULTS, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| MIKA, KELSEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| MURRAY, DONALD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
| WEINBERGER, SHMUEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2024 |
CMS files one row per role, so the 14 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 87% 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 $149K 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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146040. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-14, 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 →
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