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Sunny Hill Nursing Home Of Will County

421 Doris Avenue, Joliet, IL 60433 · Government - County · 157 certified beds · (815) 727-8710 Medicare & Medicaid certified

Call the home — (815) 727-8710 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its facility-reported quality-measure rating is low (2/5)

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

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

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
501 Ella Ave · (815) 727-8524 · Call to confirm hours
Pharmacy
358 E Cass St · (815) 727-0033 · Call to confirm hours
Grocery
1225 Richards St · (815) 722-5503 · Call to confirm hours
Park
2nd/Wilson · Typically dawn to dusk
Place of worship
1220 Richards St · (815) 666-1746

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased12.5%13.4%15.4%better
Long-stay residents who lose too much weight3.8%6.3%5.4%better
Long-stay residents with a catheter left in their bladder1.3%0.9%0.9%worse
Long-stay residents with a urinary tract infection6.1%1.5%2.0%worse
Long-stay residents with depressive symptoms3.5%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.6%3.1%3.3%better
Long-stay residents whose ability to walk worsened27.8%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication12.3%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%91.8%95.3%typical
Long-stay residents with pressure ulcers2.1%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control31.7%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table3.8%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication5.6%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine84.8%63.1%79.4%typical
Short-stay residents rehospitalized after admission34.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit10.0%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.472.021.67worse
Long-stay outpatient ER visits per 1,000 resident days1.182.221.80better

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

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

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

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

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

33.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 52 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

33.1%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
13.0%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 13.0% 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 69 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 0.18 therapist hours per resident per day in 2026Q1 — more than 17% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF33.1%CMS range 23.7–45.951.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 7.9–16.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge13.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge10.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge15.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting65.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.6%CMS range 5.1–12.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.86
RN hours/ resident / day
0.72
LPN hours/ resident / day
3.13
Aide hours/ resident / day
4.71
Total nurse hours/ resident / day
0.58
RN hoursweekends
35.7%
Total nursing turnover
4.0%
RN turnover

How full it usually is: this home is certified for 157 beds and averages 145.7 residents a day — about 93% occupied, or roughly 11 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.13 is at or above 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 4.29 hrs/resident/day on weekends vs 4.88 on weekdays — 12% thinner on weekends. RN hours go from 0.97 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 36% 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

8
deficiencies at the latest standard inspection (2025-01-31)
6
at the previous standard inspection (2024-02-23)

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.

ABCDEFGHIJKL

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

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · Gcited before2026-06-27 · 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 follow the care plan interventions of two-person care and as a result, R1 fell from the bed during personal care and sustained a fracture. This applies to 1 of 3 residents (R1) reviewed for accidents. The findings include:The facility's 06/05/26 Initial Report to the State Agency showed Resident-R1 had a fall incident this morning, complained of pain to left hip and right knee. She (R1) was sent out to the hospital and was admitted with bilateral distal femoral fractures. Full report to follow. On 06/27/26 at 9:30 AM, R1 was in bed. R1 had a left-hand contracture. R1 stated a few weeks ago, she was receiving a bed bath, being done by V4 (CNA/Certified Nursing Assistant). R1 stated V4 did not have any other staff assisting her with the bed bath. R1 stated she was in bed, lying on her left side. R1 stated V4 rolled her too far away from her, causing her to fall from the bed, onto the floor. R1 stated she was not holding on to the side rail for support. R1 stated while on the floor, her feet, hips, leg, and head were hurting.…

    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 plan of correction
  • Actual harm · Gcited before2023-08-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to use safe transfer technique during a mechanical lift transfer. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3. This failure resulted in R1 incurring a laceration of her lip requiring sutures. Findings include: R1's admission Record dated 8/21/2023 documents R1 with diagnoses to include Anxiety, Ataxia, Stroke, Paralytic Syndrome, and Blind left eye. On 8/21/2023 at 11:20 AM R1 was transferred by facility staff from an adaptive reclining chair to her bed using a mechanical lift. R1 was noted with a healed wound to her upper left lip, both legs were contracted with her knees drawn up and with spastic movements to her upper body. A facility Final Investigative Report dated 8/10/2023 documents on 8/6/2023, R1, who utilizes a mechanical lift due to poor trunk control and limited range of motion, slipped from the mechanical lift sling as she was being transferred from her bed to an adaptive reclining chair. This report documents R1 was transferred to the hospital for…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation interview and record review the facility failed to protect a resident from a fall during care activities. This applies to 1 of 3 residents (R126) reviewed for falls in a sample of 29.The findings include:On 03/03/2026 at 11:07 AM, R126 stated he fell in the shower when he slipped off the shower chair. R126 stated only one staff member was with him when he fell. On 03/05/2026 at 9:56 AM, R126 stated he did not recall if he was wearing a safety belt while on the shower chair.On 03/05/2026 at 10:03 AM, V16 CNA (Certified Nursing Assistant) stated R126 was placed on the bath chair with the assistance of another staff member, but that person did not stay for the whirlpool bath. V16 stated she placed R126 in the whirlpool tub while he was seated on the bath chair to complete his bath. V16 stated when she opened the tub door to help R126 out of the tub, he slid off the bath chair and fell between the tub and tub door and onto his left hip. V16 stated she did not recall placing the safety belt on R126 while he was on the chair. V16 stated if a belt had been on R126, he…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-02 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    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 honor the wishes of a POA (Power of Attorney) by not administering an antidepressant medication. This applies to 1 of 1 resident (R3) reviewed for medications.The findings include: R3's admission Record showed R3 was admitted to the facility on [DATE]. R3 had multiple diagnoses which included congestive heart failure, cognitive communication deficit, major depressive disorder, and osteoarthritis.On 12/31/25 at 3:28 PM, V10 (RN/Registered Nurse) stated on 12/03/25, she received an order from the NP (Nurse Practitioner) to give R3 Zoloft (Antidepressant medication). V10 stated the order was delegated to the next shift, and the order was carried out. V10 stated she spoke with R3's POA and he stated he did not want Zoloft administered to R3. V10 stated she forgot to discontinue the medication from the EMR (Electronic Medical Record). V10 stated R3's POA did not give consent for Zoloft, but the medication was started a few days later. On 12/31/25 at 4:02…

    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 · Fcited beforedisputed · IDR2025-08-23 · 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

    Based on observation, interview and record review, the facility failed to follow guidance from the State and local health authority to control the spread of a respiratory infection. This has the potential to affect all 142 residents living in the facility. The findings include:On 8/21/2025 at 12:37 PM, V5 (CNA-Certified Nurse Assistant) was observed going into R9's room, wearing only a surgical mask and gloves. R9 was on contact and droplet precaution. V5 said she is only serving lunch and is not providing direct care, so she does not need to wear a gown. She said if she provides care, she will wear a gown.On 8/22/2025, V10 (Rehab Nurse) was observed walking down the hallway of the wing where the majority of the cases of respiratory infection were, without a mask. At 10:06 AM, V10 was seen, still without a mask, on a wing where there were no cases of respiratory infection.On 8/22/25 at 9:50 AM, V14 (LPN-Licensed Practical Nurse) was seen passing medication and was not wearing a mask. She slowly applied her mask while this writer was talking to her. On 8/22/25 at 9:56 AM, residents…

    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 · Fcited before2025-01-31 · 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 properly label/date/store food items, remove expired items, and wear hair restraints in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 1/28/25 documents the total census was 142 residents. On 1/28/25 at 10:20 AM, V12 (Dietician/Dietary Manager) said there are 2 NPO (Nothing by Mouth) resident; all other residents eat from the facility kitchen. On 1/28/25 starting at 9:31 AM, the facility kitchen was toured in the presence of V12 (Dietician/Dietary Manager). For the duration of the kitchen tour, V12's hair restraint was not covering her bangs; therefore, her hair was not properly restrained. During the kitchen tour the following was found: In walk-in cooler: 1. An opened bag of shredded carrots with manufacturer use by date of 1/12/25 and a staff handwritten date in marker of…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-31 · 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 follow fall interventions for residents who were high risk for falls. This applies to 4 of 5 residents (R99, R51, R107, R24,) reviewed for accidents and supervision in a sample of 30. The findings include: 1. On January 28, 2025, at 11:56 AM, R99 had a falling star sign outside her room door. At 1:19 PM, R99 was in bed, and she had one thick fall mat on the ground on the right side of her bed. R99 did not have a call light on the left side of the bed. On January 29, 2025, at 3:12 PM, R99 was lying in bed and her adaptive call light was on the side table, out of reach. R99 only had one thick fall mat on the right side of the bed and nothing on the left side of the bed. R99's face sheet showed she was admitted to the facility with parkinson's disease, dementia, contracture on the left wrist and left hand, cognitive communication deficit, and adult failure to thrive. R99's MDS (Minimum Data Set) dated November 20, 2024, showed R99 had…

    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 before2025-01-31 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow its catheter care policy by not having the catheter tube secured and not using warm water and soap to provide catheter care. The facility also failed to use new catheter bags and leg bags instead of reusing them and to have a resident in bed with a leg bag instead of a standard drainage bag to prevent backflow. This applies to 5 of 5 residents (R19, R59, R69, R126, and R132) reviewed for catheter care in a sample of 30. The findings include: 1.R19 is an [AGE] year-old female with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 1/28/25 at 1:50 PM, R19 was observed with an indwelling catheter with urine leaks and staining on the incontinent brief. On 1/28/25 at 1:57 PM, V6 (Certified Nursing Assistant/CNA) provided incontinent care to R19 and V6 stated that the indwelling catheter shouldn't be leaking. On 01/29/25 at 9:50 AM, V3 (Assistant Director of Nursing/ADON) stated, The indwelling catheter for R19 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-31 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 provide written notice of reason for transfer to resident and/or their representative before resident transferred to the hospital. This applies to 3 residents (R103, R137, and R20) reviewed for hospital transfers in a sample of 30. The findings include: 1. R103's Face sheet shows an initial admission date of 8/27/2020. R103's Incident Note dated 10/11/24 at 13:15 shows R103 had an unwitnessed fall. R103's Health Status Note dated 10/11/24 at 14:25 shows R103 was transferred to the hospital. R103's Health Status Note dated 10/11/24 at 18:28 shows R103 was admitted to the hospital with hyponatremia. There is no documentation of written notice of hospital transfer reason or place of transfer being provided to the resident or their representative. 2. R137's Face sheet shows an admission date of 8/24/24. R137's Health Status Note dated 10/9/24 at 13:11 shows R137 was admitted to hospital with diagnosis of chest pain. R137's Health Status Note dated 11/5/24…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-31 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide written bed hold policy to resident and/or their representative prior to the resident transfer to the hospital. This applies to 1 resident (R103) reviewed for hospital transfers in a sample of 30. The findings include: R103's Face sheet shows an initial admission date of 8/27/2020. R103's Incident Note dated 10/11/24 at 13:15 shows R103 had an unwitnessed fall. R103's Health Status Note dated 10/11/24 at 14:25 shows R103 was transferred to the hospital. R103's Health Status Note dated 10/11/24 at 18:28 shows R103 was admitted to the hospital with hyponatremia. There is no documentation of bed hold notice being provided to resident or resident representative prior to transfer to the hospital. On 1/30/25 at 11:52 AM, V10 (Assistant Administrator) stated the facility did not send the bed hold notice to R103's family for her 10/11/24 hospital transfer. The facility's policy titled, Bed Hold Policy last reviewed 1/21/25 states, Policy: It is the policy of Sunny Hill Nursing Home of Will County to inform residents and/or…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 implement services to prevent further decline in range of motion and contractures for R59. This applies to 1 of 1 resident (R59) reviewed for restorative nursing in a sample of 30. The findings include: R59 is an [AGE] year-old female with severe cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 01/28/25 at 10:38 AM with V15 (Charge Nurse) R59 was noted with a right-hand contracture with no palm protector in place to prevent contraction. V15 stated that the palm protector should be on R59's right hand. V15 then added that she would put a towel roll in the hand and notify the therapist to get a palm protector. On 1/30/25 at 9:31 AM, V2 (Director of Nursing/DON) stated that the staff should have applied a palm protector to R59's right hand to prevent deterioration with her palm contraction. A review of the ADL self-care deficit care plan document interventions including: Apply palm protector to right hand if…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-31 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview the facility failed to label, store, and dispose of medications to facilitate a safe administration to residents. This applies to 2 of 2 residents (R41 and R114) reviewed for safe medication storage in a sample of 30. Findings include: 1. R41 diagnosis includes type 2 diabetes mellitus with unspecified diabetic retinopathy. R41's current physician's orders includes insulin Glargine inject 10 units subcutaneously at bedtime hold if blood sugar is less than 60. On 01/30/25 at 10:51 AM, the 1st Avenue medication cart was reviewed with V27 LPN (Licensed Practical Nurse). A vial of insulin Glargine had an opened-on date of 11/21/24 and an expiration date of 12/19/24. V27 stated she labels insulin with the manufacture's expiration date. She did not label the vial but know it should be thrown out in 28 days after opening. 2. R114 diagnoses includes type 2 diabetes mellitus with diabetic nephropathy. R114's current physician orders include insulin Aspart inject as per sliding scale subcutaneously before meals. On 01/30/25 at 11:14 AM, the 4th Avenue…

    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
Show the remaining 13 citations
  • Potential for harm · Dcited before2025-01-31 · 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 follow infection control practices. This applies to 3 of 5 residents (R52, R451, R19) reviewed for infection control in a sample of 30. The findings include: 1. On January 29, 2025, at 2:11 PM, V16 (Restorative CNA/Certified Nurse Assistant) was in R52's room without wearing a mask. V16 took R52 to the bathroom. At 2:46 PM, V16 re-entered R52's room without a mask on, and assisted R52 out of the bathroom. On January 29, 2025, at 2:52 PM, V16 stated the facility had residents with flu and norovirus but was not aware if they had COVID-19. V16 stated she should have been wearing a mask. R52 was admitted to the facility with diagnoses including anxiety disorder, insomnia, hypertension, long term use of antibiotics, and history of falling. 2. On January 30, 2025, at 9:25 AM, R131 was sitting in the dining room and R131 stated he had COVID-19 and he had to stay in his room. R131 stated the staff told him he needed to wear a mask in 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-02-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to provide urinary catheter care and services, and failed to provide incontinence care in a manner that would prevent the potential development of infection and to maintain hygiene. This applies to 4 of 6 residents (R20, R36, R42 and R130) reviewed for catheter and incontinence care in the sample of 30. The findings include: 1. R20 had multiple diagnoses including neuromuscular dysfunction of the bladder, hydronephrosis and calculus of the kidney, based on the face sheet. R20's electronic records showed that R20 had history of UTI (urinary tract infection). R20's quarterly MDS (minimum data set) dated January 23, 2024, showed that the resident was cognitively intact. R20's MDS showed that the resident required total assistance from the staff with regards to toileting hygiene. The same MDS showed that R20 had an indwelling urinary catheter and was always incontinent of bowel function. On February 20, 2024, at 11:17 AM, R20 was in bed, alert, oriented and verbally responsive. R20 had a urinary catheter and 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
  • Potential for harm · E2024-02-23 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    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 pureed meat portions and pureed soup and garlic bread as shown on the menu spreadsheet for the lunch meal. This applies to 4 of 4 residents (R37, R47, R140 and R145) observed for dining in the sample of 30. The findings include: Facility Fall/Winter 2023-2024 daily spreadsheet for Week 4 Wednesday lunch meal for the pureed meal included as follows: Pureed Beef Vegetable Soup (6 oz/ounce), pureed Veal Parmesan #6 scoop +1 oz/ounce sauce), pureed Linguini (#8 scoop) OR pasta of choice (#8 scoop), Italian Beans (#12 scoop, swirl pudding 1/2 cup, pureed garlic bread (#16 scoop). An alternate lunch choice of pureed pork (#8 scoop) was also shown on the menu. Facility scoop/disher and portion control charts showed that #6=5+1/3 oz, #8 =4 oz, #12 =2.875 oz, #16=2 oz. On February 21, 2024, at 9:35 AM, V10 (Cook) stated that the pureed items she prepared for the lunch meal included pureed Veal Parmesan, pureed pasta, and pureed Italian beans. On February 21, 2024, at 12:03 PM, during lunch meal service, V9…

    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 before2024-02-23 · 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 a unit refrigerator under sanitary conditions. This applies to 7 of 7 (R45, R67, R68, R83, R87, R107, R121) observed for dining in the sample of 30. The findings include: On February 20, 2024, at 12:28 PM, during lunch meal service, the refrigerator in the 2nd Avenue was noted to have smears and smudges of food debris and other miscellaneous substance on and around the handle of the refrigerator door. V11 (Dietary Aide) was seen wearing gloves and opening and closing the refrigerator to take items out for meal service in between handling plates to plate the food. V11 was notified of the cross contamination related to the same. On February 20, 2024, at 3:32 PM, the same refrigerator was monitored in presence of V12 (Certified Nursing Assistant). All the storage shelving (on the inside of the refrigerator) had areas of rust like substance along with multiple blackish colored spots of unknown substance. Multiple food items consisting of thickened juice containers, regular juices and prepared juices…

    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 before2024-02-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and changing gloves during provisions of care. This applies to 4 of 6 residents (R20, R42, R54 and R84) reviewed for infection control during provisions of care in the sample of 30. The findings include: 1. On February 21, 2024, at 11:34 AM, V14 and V15 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R54 who had a bowel movement. V14 cleaned R54's back peri-area, removed soiled items, applied new sheets and incontinence brief, and repositioned R54 while wearing the same soiled gloves. V14 removed her gloves and continued to straighten the clean bed linen and adjusted the bed position without hand hygiene. 2. On February 21, 2024, at 1:25 PM, V17 (CNA) provided incontinence care R42 who was heavily wet with urine. V17 cleaned R42 from the front to back and while wearing the same soiled gloves she applied barrier cream, placed new incontinence brief, and straightened the bed linens. After completing the incontinence…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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 and provide adaptive device to residents, to prevent further reduction in ROM (range of motion). This applies to 2 of 6 residents (R83 and R129) reviewed for range of motion in the sample of 30. The findings include: 1. R129 face sheet indicates multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R129's quarterly MDS (minimum data set) dated January 4, 2024, showed that the resident was severely impaired with cognition. R129's MDS showed that the resident had functional limitation in ROM on one side of both upper and lower extremities. The same MDS showed that R129 required maximum to total assistance from the staff with most of his ADLs (activities of daily living). On February 20, 2024, at 12:34 PM, R129 was in bed, alert and verbally responsive. R129's left hand and wrist were contracted. R129 was not able to extend his left-hand fingers without the assistance of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-23 · 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 ensure that a resident who was receiving gastrostomy tube (g-tube) feeding was not lying flat in bed while tube feeding was being administered. This applies to 1 of 3 residents (R54) reviewed for enteral feeding in the sample of 30. The findings include: On February 21, 2024, at around 11:25 AM, R54 was lying in bed with Jevity infusing at 40 ccs (cubic centimeters) per hour through the g-tube. R54's head of bed was elevated less than 30 degrees. On February 21, 2024, at 11:34 AM, V14 and V15 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R54 who had a bowel movement. R54 was lying flat in bed and the g-tube feeding was running while R54 was being cleaned. During the care R54 was turned to her right side and left side flat while the g-tube feeding was still running. After completing the incontinence care, V15 and V16 elevated R54's head of the bed (HOB) to about 25 to 30 degrees. On February 21, 2024, at 11:49 AM, V16 (Wound Care) stated that HOB/head of bed should be 45 degrees and 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
  • Potential for harm · Ecited before2023-03-23 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent potential urinary tract infection (UTI). The facility also failed to ensure that the indwelling catheter drainage bag was not touching the floor. This applies to 4 of 4 residents (R42, R101, R119, R134) reviewed for incontinence and urinary catheter care in the sample of 27 residents. The findings include: 1. On 3/21/23 at 3:41 PM, V13 and V14 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R42 who was wet with urine and had a bowel movement. There was redness in the abdominal folds and excoriation to front and back of the peri-area, and groins. V13 wiped R42 from the abdominal folds down to mid perineum, then she proceeded to clean the back perineum. V13 did not separate the labial folds to clean the inner area and she did not wipe the groins. 2. On 3/21/23 at 4:19 PM, V13 and V14 provided peri-care to R134 who has an indwelling urinary catheter. R134 also had…

    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 · E2023-03-23 · tag F0805 — failed to prepare food in a form residents can eat — pattern
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 puree food was prepared to a smooth consistency for the dinner meal. This applies to all the 11 residents (R5, R7, R12, R16, R19, R24, R55, R60, R92, R98, R119) who are receiving pureed diet in the facility in the sample of 27. The findings include: On 3/20/23 at 2:00 PM, V9 (Cook) pureed food for dinner time. V9 stated she's making pureed Philly Steaks for 12 servings. V9 placed 24 oz of beef, 3 cups of liquid (Meat Broth), 1 cup of thickener and 1 cup of shredded cheese in the blender. V9 pureed all these ingredients together. After pureeing the beef (Philly Steak), the state representative tasted it, the consistency was not smooth, it was grainy. State representative brought this to the attention of V9. She (V9) did not taste it and responded by saying that she will place the pureed beef in the oven which would soften it up more. V9 proceeded to put it in the container trays and covered it with plastic wrap and foil without tasting it. On 3/20/23 at 4:38 PM, V17 (Dietary Aid) was in the unit (1st…

    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 before2023-03-23 · 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 observation, interview, and record review, the facility failed to flush a resident's gastrostomy tube when disconnecting an enteral feeding. This applies to 1 of 3 residents (R28) reviewed for tube feeding in the sample of 27. The findings include: R28's EMR (Electronic Medical Record) showed R28 was admitted to the facility on [DATE], with multiple diagnoses including hereditary ataxia, dysphagia, dementia, chronic kidney disease, and paralytic syndrome. R28's MDS (Minimum Data Set) dated December 29, 2023, showed R28 had severe cognitive impairment. R28's Order Summary Report dated March 22, 2023, showed an order for [Tube feeding], give 55 milliliters an hour via G-tube (gastrostomy tube) one time a day related to gastrostomy tube. Off at 12 noon. On March 21, 2023, at 3:39 PM, V15 (LPN/Licensed Practical Nurse) entered R28's room and said R28's tube feeding had been off since noon. V15 stated she was unsure why the tube feeding was still connected to R28's gastrostomy tube since it had not been…

    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 · D2023-03-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure that narcotic medication administered to residents was recorded according to the facility's-controlled substances policy. This applies to 2 of 2 residents (R294, R295) reviewed for medication storage in the sample of 27. The findings include: On March 22, 2023, at 10:20 AM, during review of the unit medication cart with V16 (Licensed Practical Nurse) the narcotics logbook was reviewed. When V16 was asked if she had administered any narcotics (controlled substances) on her shift that day, V16 reported she administered hydrocodone to R295 at 7:52 AM, and hydromorphone to R294 at 7:22 AM. The facility's Controlled Drug Receipt/Record/Disposition Form for these respective residents was reviewed, and it was noted that neither of these narcotic medications was recorded as administered to R294 and R295. When asked about this lack of documentation of the narcotic medications, V16 confirmed that she had not documented either dose when administered to the above-mentioned residents. V16 added that it was her usual practice to…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-23 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to changing of gloves and hand hygiene during provisions of care. This applies to 2 of 27 residents (R101, R134) reviewed for infection control in the sample of 27 residents. The findings include: 1. On 3/21/23 at 4:19 PM, V13 and V14 (both Certified Nursing Assistants/ CNAs) provided peri-care to R134 who had an indwelling urinary catheter. R134 also had small bowel movement. V13 cleaned the resident from front to back. V13 then changed her gloves and without performing hand hygiene V13 applied clean incontinence brief and repositioned R134. On /22/23 at 1:04 PM, V2 (Director of Nursing/DON) stated that when staff are providing incontinence care to residents the staff must perform hand hygiene before and after care. They should also remove gloves and do hand hygiene before they proceed to another task. This is to prevent cross contamination and spread of infection. 2. R101 has multiple diagnoses which includes generalized muscle weakness, stage 3…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-23 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to offer residents the pneumococcal vaccine. This applies to 3 of 6 residents (R15, R8, and R81) reviewed for immunizations in the sample of 27. The findings include: The EMR (Electronic Medical Record) showed R15 was admitted to the facility on [DATE]. Facility documentation showed R15 received the PCV13 (13-valent pneumococcal conjugate vaccine) on November 21, 2018. On March 22, 2023, at 12:16 PM, V10 (IP/Infection Preventionist Nurse) stated [R15] has not been offered the PPSV23 (23-valent pneumococcal polysaccharide vaccine) because it has not been five years since his last pneumococcal vaccine. On March 22, 2023, at 1:33 PM, V2 (DON/Director of Nursing) stated the facility follows the CDC (Centers for Disease Control and Prevention) guidelines for the timing of pneumococcal vaccines. The facility does not have documentation to show R15 was offered or administered a second pneumococcal vaccine. 2. The EMR showed R8 was admitted to the facility on…

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

    Infection Control 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.

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
COUNTY OF WILLOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 05/12/1966
FELKINS, MICHELLEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 10/01/2017
MCDOWELL, MARGARETIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/24/2025

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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$18.9M
Net patient revenuemost recent cost report
-20.6%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 69%Medicare 4%Other / private 27%

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

$451per resident / day
operating cost
$13,717per month
≈ monthly operating cost
$374per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145892. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-31, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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