Spring Creek

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.

52.2% 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 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 11.1% 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 36 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 0.11 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 168 beds and averages 118.1 residents a day — about 70% occupied, or roughly 50 beds typically open. It usually has some room. 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 2.67 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.55 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 2.30 hrs/resident/day on weekends vs 2.81 on weekdays — 18% thinner on weekends. RN hours go from 0.40 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 18% is below the national median of 45%.

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

Inspection trend

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.

33 citations, most serious first. The 13 most serious are shown; the remaining 20 are one tap away and print in full.

• Actual harm · Gdisputed · IIDR2025-12-12 · 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

  Based on observation, interview, and record review, the facility failed to implement nutritional interventions for a resident (R10) with a known significant weight loss. This failure resulted in R10 experiencing additional significant weight loss of 10.3% in one month. The facility also failed to serve residents double portions as ordered.This applies to 3 out of 4 (R10, R27, and R106) residents reviewed for nutrition in a sample of 27.The findings include:1. R10's nutritional care plan initiated on 11/03/2025 said he was at risk for compromised nutritional status. The care plan's goal was for R10 not to experience any further weight loss. The interventions included for R10 were to serve his nutritional diet as ordered.On 12/09/2025 at 12:55 PM, R10 was confused in the dining room for lunch. R10 was thin and appeared frail. V4 (Restorative Nurse) served him his lunch, which included single portion servings of regular turkey, mashed potatoes, and mixed vegetables. V4 reviewed R10's ticket and said he did not receive the double portions as indicated on his meal tray.R10's meal ticket…

  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 before2025-03-20 · 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 observations, interviews and record reviews the facility failed to implement safety interventions and provide supervision to prevent a resident from injury when drinking hot liquids. This failure resulted in R1 sustaining 1st and 2nd degree burns to her chest. This applies to 1 of 3 residents (R1) reviewed for dependent assistance with feeding in a sample of 4. The findings include: R1's electronic health record showed that on 3/9/25, R1 was sent to the local community hospital for evaluation and treatment to burns on her chest. R1 has diagnoses including quadriplegia (loss of motor and sensory function in all four limbs), C5 - C7 complete. On 3/18/25 at 10:50 AM R1, who is alert and oriented, was in her bed with a picture of water and a large cup of ice coffee with extra-long flexible straws that reached R1's mouth. R1 said that on 3/9/25 she was alone drinking her hot cup of coffee. The cup of coffee did not have a lid on the cup, and she used a straw to drink it. R1 said coffee came out of the straw and burned her chest and she was sent to the emergency room for 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-09-10 · 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 to a cognitively impaired resident, while outdoors, to prevent prolonged sun exposure that resulted in burns to the skin. This applies to 1 of 3 (R1) residents reviewed for improper nursing care. This failure resulted in R1 obtaining full thickness burns to the upper back and posterior neck due to prolonged sun exposure. The findings include: R1 was identified by the facility with a skin condition incident report dated July 28, 2024, and identified on the facility wound report as a resident with full thickness skin injury. R1's New Skin Condition report, dated July 28, 2024, written by V9 (RN) showed R1 was noted with blisters left shoulder to mid back. The report also showed R1 required a cream be applied to R1's face and arms. On September 9, 2024, at 2:43 PM, V9 stated that she recalls R1's face and arms were also discolored and required treatment and stated the skin injuries were determined to be caused by sunburn. R1's Initial…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 secure and store cleaning supplies, safely transfer residents, and implement positioning and fall interventions.This applies to 4 of 6 residents R29, R61, R106, R111 reviewed for safety hazards in a sample of 27.Findings include: 1) On 12/09/2025 at 11:12 AM, an unsecured cleaning cart in a residents' room hallway had an 8oz (Ounce) bottle of dermal wound cleanser with blue liquid, a 1qt (Quart) generic spray bottle with fluid, and a 1 qt bottle of pine cleaning product. On 12/09/2025 at 11:22 AM, V22 Housekeeper returned to the unsecured cart stating she stepped away to throw out garbage. V22 stated she retrieved the wound cleanser bottle from the trash. V22 stated she put glass cleaner in the wound cleanser bottle because her previous bottle had broken. She was going to request a new bottle from her supervisor later. V22 stated the generic spray bottle contained bleach. V22 stated the cart did not have a locked compartment to secure…

  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 · E2025-12-12 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to label and securely store drugs and biologicals for 7 out of 7 residents (R86, R111, R130, R57, R49, R73, & R91) reviewed for medications in a sample of 27.The findings include:1.On [DATE] at 1:00 PM a check of the facility's medication cart #3 was conducted with V3 ADON (Assistant Director of Nursing) and the following was found: R86's open bottle of antiacid and anti-gas without an open date on it. R111's open bottle of Levetiracetam (Keppra) (Anticonvulsant) 100mg/ml quantity 300 without an open date on it. R130's open bottle of Lactulose (Laxative) 16 oz without an open date on it. R57's open bottle of Valproate Sodium (Anticonvulsant) 250/5ml 16 oz bottle without an open date on it. The following stock medications and biologicals were found: 1 open bottle of Geri-Tussin DM 16 oz bottle (cough suppressant and expectorant) without and open date on it. 1 open bottle of Polyethylene Glycol 3350 (laxative) 17.9 oz without an open date…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-12-12 · tag F0812 — failed to store, cook, and serve food safely — pattern
  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 maintain the kitchen in a manner that prevents foodborne illness.This applies to all 114 residents receiving dietary services.Findings include:On 12/09/2025 9:40 AM, V21 Dietary Manager confirmed 114 residents were receiving dietary service on the survey start date of 12/09/25.On 12/09/2025 9:40 AM, the kitchen tour was begun with V21 Dietary Manager.Dry Storage contained a 25 lb. (Pound) bag of great northern bean that were open to air.The Kitchen cooler #2 had a facility container that contained hard boiled eggs with an expiration date of 7/14/25.A 30lb bucket of beef base was open to air with the lid sitting loosely on top of it, and a 30lb. bucket of chicken base were being stored underneath the kitchen sink.Two silver facility pans containing yellow cake were on the counter in splashing distance of the kitchen sink.Two red sanitization buckets were in use both testing at 400 PPM (Parts Per Million)The serving utensils in open bins were dirty with dried crusted food. Two stacks of three silver mixing bowls…

  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 · Ecited before2025-12-12 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to use PPE (Personal Protective Equipment) and perform hand hygiene when rendering care.This applies to 4 out of 4 (R7, R9, R29, and R118) residents reviewed for infection control in a sample of 27.The findings include:1. On 12/11/2025 at 10 AM, V19 (Registered Nurse/RN) was administering R9's enteral feeding via her gastrostomy tube (g-tube). R9 had an EBP (Enhanced Barrier Precaution) sign on her door. V19 was only wearing gloves when rendering care to R9. R9's care plan said she required the implementation of EBP due to her g-tube, urinary catheter, and wound. The care plan's goal was to prevent the spread of infection. 2. On 12/11/2025 at 10:15 AM, V19 (RN) was assessing and flushing R7's g-tube. R7 had an EBP sign on his door. V19 was only wearing gloves when rendering care to R7. R7's care plan said he required the implementation of EBP due to his g-tube and wound. The care plan's goal was to prevent the spread of infection. 3. On 12/11/2025 at 11:25 AM, V20 (Licensed Practical Nurse/LPN) was administering…

  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 · D2025-12-12 · 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 observation, interview and record review, the facility failed to maintain a resident's bodily privacy. This applies to 1 of 1 resident (R96) reviewed for resident's dignity in the sample of 27. The findings include:On 12/11/25 at 10:14 AM, R96 was sitting on the floor, in the common area across from the nurses station, in front of the elevator. R96's pants were pulled down to his knees. R96's penis was not contained in the incontinence brief. V29 (Social Services Director) was sitting at the nurses station with his back towards R96. On 12/11/25 at 10:16 AM, V30 (CNA/Certified Nursing Assistant) stepped off of the elevator and saw R96 sitting on the floor. V30 alerted V29 and they walked over to R96 and assisted him with getting up from the floor. When R96 stood up, his penis was fully exposed outside of the incontinence brief. On 12/11/2025 at 11:10 AM, V29 stated R96 had a behavior of undressing in public places. V29 stated R96 should not have been in the common area undressed. V29 stated it is 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-12 · tag F0567 — failed to protect residents' money held by the home — isolated
  Honor the resident's right to manage his or her financial affairs.
  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 allow prompt access to requested personal funds. This applies to 1 of 1 resident (R117) reviewed for resident's personal funds in the sample of 27. The findings include:On 12/09/25 at 11:45 AM, R117 was sitting in a wheelchair in his room. R117 stated he asked V28 (Assistant Administrator/Human Resources) for $40 from his personal funds account three weeks ago. R117 stated he never received the requested money.On 12/11/2025 at 8:58 AM, V28 stated R117 had a balance $160 dollars in his account. V28 stated two weeks ago R117 asked for $40. V28 stated she did not get a chance to go to the bank to get the money. V28 stated residents should not have to wait for two weeks or more to get requested money from their account. V28 stated she was the only person who could get money from the bank. R117's admission Record showed R117 was admitted to the facility on [DATE], with multiple diagnoses which included hemiplegia and hemiparesis, morbid…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-12 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to report an allegation of abuse.This applies to 1 of 2 residents R121 reviewed for allegations of abuse in a sample of 27.Findings include:R121's MDS (Minimum Data Set) dated 10/16/25 shows she is cognitively intact. R121's diagnoses includes Arnold Chiari Syndrome, craniofacial dysostosis, monocular exotropia right eye, seizures. Scoliosis, dysthymic disorder. Current care plan includes R121 has a selfcare deficit. R121 is usually continent of bowel and bladder. She has limited use of extremities and uses a motorized wheelchair for locomotion. She requests bedpan during the night, uses a push pad call light system 1 to 1 staff assist with meals. Interventions include 1 assist with dressing, assist to toilet 1 person assist, provide extensive assist with toileting and toilet hygieneOn 12/09/2025 at 11:44 AM, R121 stated she requested toileting assistance and to be showered from V26, Certified Nurse Assistant (CNA). R121 stated her period had started and she needed to be toileted. R121 stated V26 told her to go to the toilet…

  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 before2025-12-12 · 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

  Based on observation, interview, and record review, the facility failed to provide ensure the Nurse Practitioner or MD (Medical Doctor) were notified about missed medications, and failed to perform assessments and obtain orders for the use of continuous blood glucose monitoring. This applies to 2 of 2 residents (R34, R5) reviewed for quality of care in a sample of 27.The findings include: 1) On December 9, 2025, at 12:21 PM, V9 (RN/Registered Nurse) prepared R34's medications for her. V9 said R34 refused her morning medications earlier as she was nauseous. V9 said she gave R34 Zofran earlier and she had just gone to check on her and R34 had told her she would take her medications. V9 pulled R34's medications, which included three medications that had twice daily dosing: -Amantadine hydrochloride 100 MG (milligrams) tablet, due at 9 AM and 5 PM, -Docusate sodium 100 MG tablet, due at 9 AM and 5 PM, -Gabapentin 300 MG capsule, due at 9 AM, 1 PM, and 5 PM. On December 9, 2025, at 1:05 PM, V9 administered R34's medications to her. On December 11, 2025, at 2:26 PM, V18 (NP/Nurse…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-12 · 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

  Based on observation, interview, and record review, the facility failed to follow gastrostomy tube feeding orders, label feeding bottles, and maintain the tube site.This applies to 1 out of 3 (R7) residents reviewed for gastrostomy tubes in a sample of 27.The findings include: On 12/09/2025 at 10 AM, R7 was in bed receiving his g-tube (gastrostomy tube) feeding via a pump. R7's hanging feeding was in a clear bag connected to a water bag, both were not labeled. R7 had an open g-tube feeding bottle of (Nutritional Product) on his bedside table.On 12/10/2025 at 11:40 AM, R7 said he was dependent on staff for his care, and his feeding was just disconnected. R7's gastrostomy tube site did not have a dressing and had brown-thick adherent drainage around his tube.On 12/11/2025 at 9 AM, R7 was in bed connected to his g-tube feeding. R7's hanging feeding bag again was not labeled with the type of feeding being infused. The pump had a beeping alarm notifying that the pump was inactive. At 9:25 AM, V27 (Wound Nurse) assessed his tube site, and again there was brown-thick adherent drainage…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-12 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders to maintain a medication error rate of less than 5%. There were 38 opportunities for error with 4 medication errors, resulting in an error rate of 10.53%.This applies to 1 of 3 residents (R34) observed during medication pass.The findings include: On December 9, 2025 at 12:21 PM V9 (RN/Registered Nurse) was preparing R34's medications. V9 said she did not administer R34's medications at 9 AM as R34 was nauseous. At 1:05 PM, V9 finished preparing R34's medications and administered them to her. V9 came back to the computer and signed off her medication and said she had completed administering R34's medications. Upon medication reconciliation, the following medication errors were found: 1. Amantadine Hydrochloride (HCL) 100 MG (Milligram) oral tablet, to be administered at 9 AM and 5 PM, was administered at 1:05 PM. 2. Docusate Sodium 100 MG oral tablet, to be administered at 9 AM and 5 PM, was administered at 1:05 PM. 3. Gabapentin 300 MG…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

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

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$19,135 in federal fines across 1 penalty.

• $19,135 — penalty dated 2025-12-12

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 SABA HEALTHCARE — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 5 rows in the source record cover these 3 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.

About 90% 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 $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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