Jerseyville Nsg & Rehab Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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

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

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

60.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 61.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 21 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 111 beds and averages 55.6 residents a day — about 50% occupied, or roughly 55 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 2.65 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 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 2.43 hrs/resident/day on weekends vs 2.75 on weekdays — 12% thinner on weekends. RN hours go from 0.45 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%.

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

Inspection trend

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

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.

49 citations, most serious first. The 23 most serious are shown; the remaining 26 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-09-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility failed to ensure its door alarms were loud enough to be heard from areas away from the 200 hall exit door and its outside gait latch was in working order to prevent elopement in 1 of 4 residents (R2) reviewed for elopement in the sample of 4. This led to R2 eloping from the facility, which is located on a busy intersection and approximately 100 yards from an active railroad track. The Immediate Jeopardy began on 8/22/25, when R2 eloped from the facility. On 9/16/25 at 10:45 AM, V1, Administrator, and V2, DON, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 9/16/25 but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include:On 9/16/25 at 8:20 AM, this surveyor went to the 100/300 nurse's station and V7 activated the 200-hall door alarm, it could not be heard from the 100/300 hall nurse's station until approximately 20 feet down the 200 hallway, and when it was heard, the surveyor…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-10-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect residents from sexual abuse for 2 of 5 residents (R3, R4) reviewed for abuse in the sample of 15. This failure resulted in immediate jeopardy on 7/31/24 when the facility first identified the sexual behaviors between R3 and R4 and failed to put interventions in place to ensure every effort was taken to protect R3. This failure resulted in R4 displaying sexual behaviors towards R3, including fondling her breasts, placing his hand in her pants and R3 and R4 observed in R4's room, both with their pants and underwear down and R4 kneeling in front of R3. R3 and R4 have moderate cognitive impairment and the inability to consent to sexual relations. The Immediate Jeopardy began on 7/31/24, when the facility first identified the sexual behaviors between R3 and R4 and failed to put interventions in place to ensure every effort was taken to protect R3. On 10/9/24 at 12:35 PM, V1, Administrator, V2, DON (Director of Nurses), V25, BOM (Business Office…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-10-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide supervision/monitoring to prevent an elopement for 1 of 6 residents (R5) reviewed for supervision to prevent elopement in the sample of 15. This failure resulted in Immediate Jeopardy on 9/20/24 when R5, eloped from the facility sometime after 3:00 AM and was found by a passerby at 6:20 AM and returned to the facility. The Immediate Jeopardy began on 9/20/24, when R5 eloped from the facility sometime after 3:00 AM and was found by a passerby at 6:20 AM and was returned to the facility. On 10/9/24 at 12:35 PM, V1, Administrator, V2, DON (Director of Nurses), V25, BOM (Business Office Manager), and V26, Regional Director, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 10/10/24, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The Facility…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2024-03-11 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a system to track and trend infections, failed to implement a system for testing for the spread of COVID-19, and failed to implement infection control procedures including isolation precautions and personal protective equipment (PPE) to prevent the spread of COVID-19. These failures resulted in 23 residents developing COVID-19, including 5 residents (R37, R51, R207, R208, and R209) who expired after becoming positive with COVID-19. Two residents (R19, and R40), and one staff member (V27, Certified Nursing Assistant/CNA) are currently positive with COVID-19. These failures have the potential to affect all 52 residents in the facility. The Immediate Jeopardy began on [DATE], when R35 developed COVID-19 and the facility failed to conduct testing and surveillance to prevent the spread of COVID-19. Subsequently, 22 other residents have developed COVID-19. Although the facility tested those with COVID-19 symptoms, the facility 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-11-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to evaluate, implement and monitor effectiveness of fall interventions to prevent falls for 1 out of 3 residents (R2); reviewed for accident hazards/supervision/devices in a sample of 4. This failure resulted in R2 sustaining depressed skull, orbital, maxillary and temporal fractures, a scalp laceration, a subdural hematoma, a subarachnoid hematoma and an intraparenchymal hematoma of the brain. Findings include:R2's Face Sheet documented she was admitted to the facility on [DATE] and was discharged on [DATE] with diagnosis of, in part, dementia with agitation, history of falling, hypothyroidism, and anxiety disorder.R2's Minimum Data Set (MDS) dated [DATE] documented she was rarely/never understood and her cognitive skills were severely impaired. It continued to document that R2 required the use of a wheelchair, substantial/maximal assistance from staff to stand, and partial/moderate assistance to sit up on the side of the bed from a lying…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-06-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, and Record Review the facility failed to timely report and treat a change in condition for 1 (R3) of 3 residents reviewed for change in condition in the sample of 5. This resulted in R3 experiencing an increase in pain and not being seen by a physician and diagnosed with a pubic fracture for 8 days. Findings include: R3's admission Record, not dated, documents an admission date of 10/28/2022. Diagnosis include Displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, Emphysema, Aneurysm of the Descending Thoracic Aorta, Dementia, Tremors. R3's Minimum Data Set, dated [DATE], documents R3 is severely cognitively impaired. R3 requires maximum/substantial assist for activities of daily living, (ADLs) and mobility. R3's Care Plan updated 5/8/2025, documents Problem: R3 is at risk for falls due to diagnosis of tremors, vertigo, dementia, arthritis of left hip, pain in left and right knee, history of falling, iron deficiency anemia, and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-02-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, and Record Review, the facility failed to provide progressive fall interventions and to complete a fall investigation for 1(R28) of 2 residents in the sample of 21.This failure resulted in R28 sustaining a displaced fracture of greater trochanter of left femur. Findings include: R28 documents an admission date of 10/28/2022. Diagnosis include Displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, Emphysema, Aneurysm of the Descending Thoracic Aorta, Dementia, Tremors. R28's Minimum Data Set, MDS, dated [DATE] documents R28 is severely cognitively impaired. R28 requires maximum/substantial assist for activities of daily living, (ADLs) and mobility. R28's Care Plan updated 1/1/2025 documents Problem: R28 is at risk for falls due to diagnosis of tremors, vertigo, dementia, arthritis of left hip, pain in left and right knee, history of falling, iron deficiency anemia, and poor safety awareness, up ad lib in facility with walker.…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-02-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide 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 obtain monthly weights on 2 of 3 residents (R13, R41), reviewed for nutrition in the sample of 21.This failure resulted in R13 having a significant weight loss of 15.6% from 11/8/24 to 2/26/25. Findings include: 1. On 2/26/25 at 8:43 AM, R13 was sitting in a specialty chair in the dining room. She appeared thin with observable temporal wasting and did not respond when spoken to. V10, Certified Nursing Assistant (CNA), stated R13 has to be fed by staff. R13's Face Sheet documents R13 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, depression, and pain. R13's Minimum Data Set (MDS) dated [DATE] documented R13 was severely cognitively impaired, ambulated via wheelchair, required substantial assistance with eating, was on mechanically altered diet, and had no or unknown weight loss. R13's Care Plan revised 2/11/24 documents R13 is at risk for hydration problems, dehydration, constipation, and urinary…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate allegations of potential abuse to prevent further sexual abuse for 2 of 5 residents (R3, R4) reviewed for investigating/implementing interventions to prevent further abuse in the sample of 15. This failure resulted in R4 displaying sexual behaviors towards R3, including fondling her breasts, placing his hand in her pants and R3 and R4 observed in R4's room, both with their pants and underwear down and R4 kneeling in front of R3. R3 and R4 have moderate cognitive impairment and the inability to consent to sexual relations. Findings include: R3's Face Sheet, undated documents R3 has the following diagnosis: Other Symptoms and Signs Involving Cognitive Functions and Awareness, Major Depressive Disorder, Amnesia, and Altered Mental Status. R3's Abuse Screener, dated 9/24/24, documents that R3 is at risk for abuse and care planning is required. R3's Progress Note, dated 7/31/24 at 3:13 PM, documents the following: (V15, R3's Daughter) 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess/monitor, provide treatments as ordered, and provide pressure relief to prevent pressure ulcers for 1 of 2 residents (R30) reviewed for pressure ulcers in the sample of 52. This failure resulted in R30 developing two facility acquired unstageable pressure ulcers to R30's left and right heels, and a Stage II pressure ulcer to his buttocks. Findings include: R30's Face Sheet, undated, documents R30 was admitted on [DATE], and has diagnoses of left femur fracture and hypertension. R30's Minimum Data Set (MDS), dated [DATE], documents R30 is moderately cognitively impaired and requires substantial / maximal assistance for staff for activities of daily living and mobility. R30's Braden Assessment, dated 1/12/24, documents R30 is a mild risk for developing pressure ulcers. R30 did not have an updated Braden Assessment after her return from the hospital on 1/27/24 with a fractured left hip. R30's Physician Orders, dated 1/28/24 - 2/28/24,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-03-11 · tag F0687 — failed to care for feet properly — isolated
  Provide appropriate foot care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide foot care, including providing current treatment and consulting with a Podiatrist for further treatment, for 1 of 1 resident (R31) reviewed for foot care in the sample of 52. This failure caused R31 to be in severe pain and have a severely reddened, swollen, and very tender fourth toe and/or foot for a long period of time. Findings include: R31's Face Sheet, undated, documents R31 was admitted to the facility on [DATE], and has diagnoses of arthritis, left hip, corns and callosities. R31's Care Plan, revised 1/10/24, documents R31 has potential/actual impairment to skin integrity related to, hypertension, history of falling, unspecified abnormalities of gait and mobility, tremor, dementia, anxiety, ambulates without assistants, fragile skin due to natural aging process. The Care Plan Approach, revised on 10/2/23, documents Weekly skin checks per licensed nurse. Document skin check in EMR (electronic medical record). 2) Treatment as…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-03-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to put progressive interventions in place and provide supervision to prevent falls for 2 of 3 residents (R30, R31) reviewed for falls. This failure resulted in R30 falling and sustaining a fractured hip, and R31 falling and sustaining a fractured arm. Findings include: 1.R30's Face Sheet, undated, documents R30 was admitted to the facility on [DATE], with diagnoses of Pneumonia, Hypertension and Shortness of Breath. R30's Nurse's Note, dated 01/04/2024 at 1:33 PM, documents, Patient arrived via (local) Emergency Medical Services with 2 attendants. Patient was in ER (Emergency Room) for two days, diagnosis fall. Patient had multiple unwitnessed falls at home. R30's Fall Risk Assessment, dated 1/4/24, documents R30 is a high fall risk. R30's Care Plan, initiated on 1/4/24, documented R30 was at risk for falls related to generalized weakness, forgets limitations, hearing impaired, unsteady gait, and occasional incontinence, Pathological…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-03-31 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor 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 respond to call lights in a timely to address residents' needs for 7 of 18 residents (R2, R5, R17, R19, R22, R32, R36) reviewed for dignity in the sample of 40. Findings include: 1. R22's Minimum Data Set (MDS), dated [DATE], documents R22 is cognitively intact. On 3/29/23 at 10:00 AM, R22 stated, I feel ignored at times. We have to wait a long time on call lights, and they always say, Let me check on that and you never see them again. I have learned that if I use the (call) light in the bathroom they come a lot faster than (if I use) the one on the bed. 2. R19's MDS, dated [DATE], documents R19 is cognitively intact. On 3/29/23 at 10:00 AM during the Resident Council Meeting, R19 stated he has to wait a long time for help when he presses his call light. 3. R5's MDS, dated [DATE], documents R5 is cognitively intact. On 3/29/23 at 10:00 AM during the Resident Council Meeting, R5 stated there are often long waits when she presses her call light. 4. R17'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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-09-16 · tag F0908 — failed to keep essential equipment working — widespread
  Keep all essential equipment working safely.
  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 its courtyard gait latch was in proper working order when reviewing for mechanical equipment in working order. This failure has the potential to affect all 50 residents residing in the facility.Findings Include:On 9/12/25 at 11:20 AM, V3, R2's Son, stated on that Friday 8/22/25, R2 had exited the facility without staff and he and V4, LPN (Licensed Practical Nurse) went outside to the fenced in courtyard and did not see her. A young lady called and stated the facility had a patient out on the road behind the facility. V3 stated the courtyard gate to the fenced in area outside the 200-hall door was not locked or latched. V3 stated when he asked about this, he was told that they could not lock/latch it because it was illegal because it could prevent residents from exiting in the event of a fire. V3 stated he had decided at that time to take R2 home to live with him, they had several care concerns and this just placed it over the top. On 9/12/25 at 1:10 PM, V2, DON (Director of Nurses), stated the latch to the gait off…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on Interview, and Record Review the facility failed to assure fall interventions were in place for 1 (R3) of 3 residents reviewed for falls in the sample of 5. Findings include: R3's admission Record, not dated, documents an admission date of 10/28/2022. Diagnosis include Displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, Emphysema, Aneurysm of the Descending Thoracic Aorta, Dementia, Tremors. R3's Minimum Data Set,, dated 2/19/2025, documents R3 is severely cognitively impaired. R3 requires maximum/substantial assist for activities of daily living, (ADLs) and mobility. R3's Care Plan updated 5/8/2025, documents Problem: R3 is at risk for falls due to diagnosis of tremors, vertigo, dementia, arthritis of left hip, pain in left and right knee, history of falling, iron deficiency anemia, and poor safety awareness related to a BIMS of 8, up ad lib in facility with walker. Falls 7/20/23, 09/27/2023, 12/1/23, 12/19/24, 12/23/24,1/3/25, 2/18/25, 3/13/25 and 3/31/25. Interventions include: Staff to toilet resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-02-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the Facility failed to ensure food was prepared, stored and distributed in a manner that prevents foodborne illness. This has the potential to affect all 48 residents living in the Facility. Findings include: On 2/25/25 at 8:45 AM, V6, Dietary Aid, placed a tray of pans in the dish machine and began the cycle. She stated she has never checked the dish machine sanitizer level. On 2/25/25 at 8:47 AM, the refrigerator labeled Fridge 2 contained a cardboard box of lettuce with sticky, red spatters on top of it. There was an opened container of whipped cream that was not dated upon opening. On 2/25/25 at 8:50 AM, the air conditioner above the toaster was covered in dust. On 2/25/25 at 8:52 AM, there was a rack of pots and pans next to the stovetop with crumbs on one of the pans. On 2/25/25 at 8:54 AM, the refrigerator labeled Fridge 1 contained a package of sliced deli meat that was opened, but was not dated or resealed after opening, leaving the contents open to air. V7, [NAME] stated, I'm not sure what that is. I think it's turkey .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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-02-28 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure 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

  Based on observation, interview, and record review, the Facility failed to serve meals in a timely manner for 4 of 4 residents (R14, R29, R19, R32) reviewed for nutritional services in the sample of 21. Findings include: The Facility's Meal Times List documents Lunch is served at 12:00 PM daily. On 2/25/25 at 12:13 PM, V7, Cook, began plating food from the steam table for residents in the dining room. On 2/25/25 at 12:54 PM, V7 continued making plates of food and stated, Today is just an off day (regarding the timing of meal). On 2/25 25 at 1:03 PM, V7 finished making plates and took a cart of trays to the nurse's station. She stated she would watch the food until Certified Nursing Assistants (CNAs) were available to pass the trays to the rooms. On 2/25/25 at 1:08 PM, V9, Certified Nursing Assistant (CNA), pushed the cart down the 100 Hallway and stated the meals are always late. On 2/25/25 at 1:19 PM, V8, Dietary Manager, took a meal tray from the cart and delivered it to R14's room. On 2/25/25 at 1:20 PM, V9 took a meal tray from the cart and delivered it to R29's room. On 2/25/25…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-28 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably 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, interview and record review, the facility failed to provide access to a sink in a resident bathroom to maintain their independence for 1 of 3 residents (R34) reviewed for accommodation of needs in the sample of 21. Findings include: On 2/25/25 at 10:30 AM, R34 was up in the wheelchair. R34 stated he can't access the sink in his bathroom with his wheelchair, staff will bring him a washcloth to wash his hands but he isn't able to get up to the sink to brush his teeth. R34's bathroom was observed and upon entering the bathroom, the toilet is directly to the right and had an elevated over the toilet riser with grab bars attached to it. The sink was located to the left of the toilet, and due to the size of the toilet riser there was not enough room for R34 to access the sink while in his wheelchair. R34's Minimum Data Set, dated [DATE], documents R34 is cognitively intact. R34's Care Plan, dated 10/11/22, documents R34 requires assistance with activities of daily living and to adapt 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to ensure residents were free from abuse for 2 of 2 residents (R15, R4) reviewed for abuse in the sample of 21. Findings include: 1. R42's Face Sheet documents R42 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. R42's Minimum Data Set (MDS) dated [DATE] documented R42 was severely cognitively impaired, ambulated via wheelchair, and had behaviors including wandering and physical verbal behaviors directed toward others. R42's Care Plan with start date of 7/23/24 documents R42 exhibited problems as seen by cursing, hitting, grabbing others, rummaging, making disruptive sounds, screaming at others, wandering and looking for a boyfriend. R15's Face Sheet documents R15 was admitted to the facility on [DATE] with diagnoses including failure to thrive, protein calorie malnutrition, and major depressive disorder. R15's MDS dated [DATE] documented R15 was cognitively intact and ambulated via wheelchair. R15's Care…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the Facility failed to investigate allegations of abuse for 2 (R15, R42) of 2 residents reviewed for abuse, neglect and exploitation in the sample of 21. Findings include: 1. R15's Progress Note dated 10/11/24 by V22, Licensed Practical Nurse (LPN) documents, Was on 200 hall passing medicine, and heard (R15) calling out. Went in room and (R42) was standing beside (R15)'s bed hitting her and telling her to get out of her room. R42's Progress Note dated 10/11/24 by V22 documents, Was passing medicine on 200 hall and heard (R15) calling out for help, and went in and found (R42) standing by (R15)'s bed. She was hitting (R15) and telling her to get out of the room. On 2/27/25 at 11:24 AM, V1, Administrator, stated he does not have an abuse investigations for this allegation. 2. R42's Progress Note dated 11/24/24 by V12, LPN, documents, Writer was called into dining room from CNA (Certified Nursing Assistant). CNA has stated that patient had got up from wheelchair and walked to another male patient and hit patient in right side of upper back closed…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-28 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  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 serve meals at a desirable temperature to 2 of 2 residents (R14, R41), reviewed for preferred temperature in the sample of 21. Findings include: On 2/25/25 at 1:03 PM, the food temperatures were checked with a metal calibrated thermometer after the last resident tray was served with the following noted: Hamburger: 169 degrees, Ground hamburger 156 degrees, French fries 107 degrees and vegetable medley 123 degrees. 1 On 2/25/25 at 11:28 AM, R14 stated the food is horrible, tastes bad, is cold and never on time. R14 stated there are times when lunch isn't served until 2:00 PM. R14's Minimum Data Set (MDS), dated [DATE], documents R14 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R14 is cognitively intact. 2. On 2/25/25 at 1:50 PM, R41 stated since he has been in isolation for COVID-19, he doesn't get his food until later than normal, it is cold by the time it gets to him and the meat tastes horrible. R41's Face Sheet,…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-02-28 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to ensure use of proper PPE (Personal Protective Equipment) for 2 of 3 isolated residents (R39, R42) reviewed for infection control in the sample of 21. Findings include: 1. R39's Face Sheet documents R39 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). R39's Progress Note dated 2/23/25 documents R39 did not feel well and requested a Covid test which resulted positive. R39's Progress Note dated 2/24/25 documents R39 had a sore throat and remained on isolation for Covid. R39's Progress Notes dated 2/25/25 and 2/26/25 document R39 remained on isolation for Covid. On 2/25/25 at 4:08 PM, V13, Certified Nursing Assistant (CNA) was in R39's room passing water with the door open. She was not wearing a gown or gloves, and her mask was down below her nose. She stated she was not wearing a gown or gloves because she was just passing water. On 2/26/25 at 7:45 AM,…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-26 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observations, record review the facility failed to assess and monitor a Gastrostomy tube site for 1 of 2 residents (R2) reviewed for feeding tubes in a sample of 6. Findings include: R2's Face Sheet, not dated, documented that R2's original admission date was 9/30/3019 was readmitted to the facility on [DATE] with a diagnosis of dysphagia and adult failure to thrive. R2's minimum data set (MDS), dated [DATE], documented that R2 is moderately cognitively impaired. MDS indicated that she requires assistance with activities of daily living (ADL). R2 receives a mechanically altered diet. R2's Care Plan, updated on 10/07/2024, documented that R2 refuses to follow mechanical diet and chooses to eat regular textured food despite being educated on the risks of choking. Care plan dated 10/05/2024 documented that R2 receives tube feeding for support to nutritional oral intake. The goal is that R2 will be adequately nourished and hydrated as evidenced by maintaining weight. The approaches are flushes as…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$399,920 in federal fines across 7 penalties. 3 Medicare payment denials on record.

• $35,770 — penalty dated 2026-04-24
• $10,056 — penalty dated 2025-09-16
• $16,575 — penalty dated 2025-09-16
• $32,214 — penalty dated 2025-06-10
• $61,789 — penalty dated 2025-02-28
• $80,789 — penalty dated 2024-10-10
• $162,727 — penalty dated 2024-03-11
• Medicare payment denial — starting 2025-10-06 for 38 days
• Medicare payment denial — starting 2025-03-25 for 17 days
• Medicare payment denial — starting 2024-11-08 for 19 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 HELIA HEALTHCARE — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $226K 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