Citadel Care Center-Kankakee
900 West River Place, Kankakee, IL 60901 · For profit - Limited Liability company · 107 certified beds · (815) 933-1711 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 4 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 improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 3.0% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.9% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 100.0% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.8% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.9% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 27.8% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.9% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.0% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 15.5% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.3% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.3% | 2.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 78.4% | 63.1% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 38.2% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 19.3% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.95 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.51 | 2.22 | 1.80 | better |
‡ 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.
32.5% 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 82 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 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 0.19 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 32.5%CMS range 25.4–41.6 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 7.2–16.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 40.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 27.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 36.4% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 97.5% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.6%CMS range 5.3–15.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.34 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 107 beds and averages 92.4 residents a day — about 86% occupied, or roughly 15 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 3.23 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 2.95 hrs/resident/day on weekends vs 3.34 on weekdays — 12% thinner on weekends. RN hours go from 0.42 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% 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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2024-01-12 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 address pain before and during wound care to a resident. This failure has caused severe pain for one resident during dressing changes. This applies to 1 of 2 residents (R54) reviewed pain management in a sample of 31. The Findings include: R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. On 1/10/24 at 2:20 PM, observed V5 (Wound Care Nurse) and V7 (Certified Nursing Assistant - CNA/Memory Care Director) begin to provide wound care to R54's coccyx wound without assessing for pain. Observed V5 and V7 using the mattress linen to pull him up on the bed and R54 complaining of pain, saying, I have too much pain. In response to R54's pain, V5 said to R54, I know your nurse gave you pain medication. On 1/10/24 at 2:25 PM, V5 and V7 turned R54 to his right side to provide wound treatment to his coccyx wound. V5 sprayed wound cleanser on his unstageable wound (as per…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to remove expired food items, reseal opened food items, and maintain temperature of freezer to keep foods solid. 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 11/19/24 documents that the total census was 88 residents. On 11/19/24 at 11:33 AM, V12 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On 11/19/24 starting at 11:04 AM, the facility kitchen was toured in the presence of V12 (Dietary Manager) and the following was found: Dry Storage: 1. 2-1 quart cartons of cultured reduced fat buttermilk dated best if used by 11/13/24. Expired. 2. 1 quart of French vanilla coffee creamer dated best by 9/24/24. Expired. 3. 8 ounce container of sour cream best by 7/2/24. Expired. Reach in freezer in dry storage room: 4. An opened, not sealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-11-22 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review, the facility failed to maintain a QAA (Quality Assessment and Assurance) committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and the infection preventionist. This has a potential to affect all the residents in the facility. The findings include: On 11/21/24 at 09:23 AM, V1 (Administrator) said the Medical Director has not been to any QAA meetings in over a year. A review of all the facility's QAA attendance sheets for the last year, January - March 2024, April - June 2024, & July - September 2024 showed that the facility's Medical Director had not signed the attendance sheets. A review of the facility's 11/19/24 - 11/22/24 Long-Term Care Facility Application for Medicare and Medicaid showed a census of 88 residents.
- Potential for harm · D2024-11-22 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 treat all residents with respect and dignity. This applies to 1 resident (R47) reviewed for dignity in a sample of 25. The findings include: On 11/19/24 at 12:34 PM, R47 was observed in the hallway with yogurt spilled down the front of her sweatshirt and dripping down her face. V15 (Housekeeper) and V16 (LPN/Licensed Practical Nurse) walked past R47 and V15 said to R47, Oh my gosh look at your face! V16 (LPN) then whispered something to V15 (Housekeeper) and V15 said, What did I say wrong? People don't wipe it! R47 continued to walk down the hall and turned the corner and V15 and V16 walked down the hall in the opposite direction and did not stop to help clean up R47. On 11/21/24 at 1:08 PM, V2 (DON/Director of Nursing) said since R47 was up and walking around in the hallway, the staff should make sure she looks presentable. V2 said it is a dignity issue that R47 was not assisted and cleaned up when she was seen by staff with yogurt on her face and clothing. V2 said she didn't know why V15 would have made a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-22 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice) Form CMS-1005 in writing to all residents who were discharged from Medicare Part A services with benefit days remaining. This applies to 3 residents (R47, R242, R91) reviewed for Advanced Beneficiary Notice and financial liability in a sample of 25. The findings include: V11 (BOM/Business Office Manager) filled out SNF Beneficiary Protection Notification Review Form CMS- 20052 for R47 and documented Medicare Part A skilled services start date was 8/16/24 and last covered day of Part A service was 10/4/24. V11 documented the facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. V11 wrote the SNFABN was not provided to the resident/beneficiary because the NOMNC was issued. V11 filled out the SNF Beneficiary Protection Notification Review Form-20052 for R242 and documented Medicare Part A skilled services start date was 2/24/24 and last covered day of Part A service was 5/10/24. V11 documented the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-22 · tag F0623 — isolatedProvide 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 a resident and/or their family/POA (POA/Power of Attorney) in writing for the reason of transfer to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 3 of 3 residents (R48, R64, and R78) reviewed for discharge in a sample of 25. The findings include: 1. On [DATE] at 1:38 PM, V1 (Administrator) stated we haven't been giving the residents or their representatives written documentation as for the reason the residents are sent out to the hospital. We call the family when they are transferred. I did not know we had to give the written documentation. The ombudsman should be notified of all discharges, transfers, and hospital admissions. We hadn't notified the ombudsman in the past. R48's Face Sheet showed R48 was admitted to the facility on [DATE]. R48 had multiple diagnoses which included Alzheimer's, asthma, convulsions, syncope and collapse, major depressive disorder, and schizophrenia. R48's Progress…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-22 · tag F0625 — isolatedNotify 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide in writing to the residents and/or their POA (POA/Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 3 of 3 residents (R48, R64, and R78) reviewed for discharge in a sample of 25. The findings include: 1. On [DATE] at 1:38 PM, V1 (Administrator) Residents or the resident's representatives should have a bed policy given to them when they go out to the hospital. R48's Face Sheet showed R48 was admitted to the facility on [DATE]. R48 had multiple diagnoses which included Alzheimer's, asthma, convulsions, syncope and collapse, major depressive disorder, and schizophrenia. R48's Progress Notes showed the following: On [DATE] At 1500 resident was sitting in the dining room with the activities. Quiet with eyes closed but breathing. At 1533 CNA's (CNA/Certified Nursing Assistant) observed that resident was not breathing. They did not see her chest rise or fall and brought her to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide personal hygiene for 3 residents (R29, R86, & R64) who are dependent on ADL care (Activities of Daily Living) in a sample of 25. Findings include: 1. On 11/19/24 at 12:25 PM, R29 was observed with her nails long, jagged and with brown substance under the nails and her hair was oily. V5 (R29's niece) was present at that time and said that the staff needs to cut and clean her nails. R29's EHR (Electronic Health Record) showed that she is a [AGE] year old female admitted to the facility on [DATE]. Her 10/18/24 MDS (Minimum Data Set) showed that cognitive skills for daily decision making are severely impaired, and she has long and short term memory problems. Her 10/10/24 MDS section GG showed that she is dependent on staff for personal hygiene. 2. On 11/19/24 at 12:41 PM, R64 was with V4 (R64's Brother) and her hair was observed oily, and she had an excessive amount of hair on her chin and upper lip. The hair was about 1 to 1 ½ inches…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
Based on observation, interview, and record review, the facility failed to ensure anti-contracture devices were applied to resident as ordered. This applies to 1 of 2 residents (R16) reviewed for anti-contracture devices in a sample of 25. The findings include: On 11/19/24 at 11:51 AM, R16 was observed in the dining room, sitting in her high back wheelchair participating in activities with other residents. R16 's right hand was in fist form laying on her abdomen. When asked if R16 wears an anti-contracture device, R16 smiled, did not respond. On 11/20/24 at 11:07 AM, R16 was observed in the dining room, siting in high back wheelchair, right hand still in fist form, no splint. Review of R16's Electronic Medical Record shows that R16 has the following diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness and muscle wasting and atrophy. R16's Minimum Data Set (MDS) of 10/3/24 shows that R16's cognition is severely impaired. R16's Physician order shows to have right hand palm protector, to wear at all times and take off for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-11-22 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to properly position indwelling catheter drainage bag during wound care dressing change. This applies of 1 of 2 residents (R22) reviewed for indwelling catheter in a sample of 25. The findings include: On 11/20/24 at 9:58 AM, V9 (Wound Care Nurse Manager) and V10 (Memory Care Coordinator) provided wound care treatment to R22. At 10:09 AM, V9 unhooked R22's catheter drainage bag from the right side of the bed and placed the bag on R22's bed, while V10 turned R22 to her left side so that V9 could access R22's sacral wound. V9 completed R22's sacral wound dressing change, left the drainage bag on the bed. After the dressing change, V9 and V10 repositioned R22 in bed, and R22's catheter bag was under R22's leg. At 10:25 AM, V9 and V10 left R22's room, the catheter bag was still on the bed. At 11:00 AM, R22's catheter bag was still on the bed under R22's leg. Review of R22's Electronic Medical Record shows that R22 has the following diagnoses of osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-31 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to notify the POA (POA/Power of Attorney) of changes in condition. This applies to 1 of 3 residents (R1) reviewed for policy and procedures. The findings include: On 01/30/24 at 1:53 PM, V4 (CNA/Certified Nursing Assistant) said she takes care of R1 all the time. V4 said she was taking care of R1 on 01/11/24 during the 6:30 AM-2:30 PM shift when she saw bulging to R1's right hip. V4 said she did not see any bruising on 01/11/24. V4 said she first saw the bruising a few days later after seeing the hip bulging. V4 said the bulging of the right hip had never looked that big before. V4 said she asked R1 if she was in pain and R1 said no. V4 said she told the nurse, V5 (LPN/Licensed Practical Nurse). V4 said V5 came in the shower room and assessed R1. V4 said she assumed V5 told the family about the bulging right hip. V4 said when I see bruising or anything abnormal, I report it to the nurse, the supervisor, and the abuse coordinator. On 01/30/24…
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.
Show the remaining 12 citations
- Potential for harm · Fcited before2024-01-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to properly label, date, seal, and store food items in the 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 1/9/24 documents that the total census was 94 residents. On 1/10/24 at 11:26 AM, V3 (Director of Food and Nutrition Services) said there are no NPO (Nothing by Mouth) residents and all 94 residents eat from the facility kitchen. On 1/9/24 starting at 10:32 AM, the facility kitchen was toured in the presence of V3 and the following was found: Dry Storage: 1. Twelve 2 pound bags of sun dried raisins with expiration date 8/25/23. 2. One 6 pound 9 ounce can of diced pears dated 11/15 with a large dent on rack of food to be served. V3 said the dented cans are supposed to be removed from circulation and not used because of the risk of botulism. 3. One 6 pound 9 ounce can of diced pears with no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-12 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide personal care to dependent residents. This applies to 5 of 5 residents (R9, R14, R16, R32, and R54) reviewed for ADL's (ADL's/Activities of Daily Living) in the sample of 31. The findings include: 1. On 01/09/24 at 10:57 AM, R9 had stubble facial hair above the lip, under the chin, and both cheeks. R9 stated he wanted to be shaved. On 01/10/24 at 11:25 AM, R9 continued to have stubble facial hairs above the lip, under the chin, and both cheeks. R9 said he still wanted to be shaved. On 01/11/24 at 10:20 AM, R9 still had stubble facial hairs. R9's face sheet showed R9 had the following diagnoses chronic obstructive pulmonary disease, emphysema, insomnia, unsteadiness on feet, abnormalities of gait and mobility, malaise, dementia with anxiety, low back pain, right hip pain, major depressive disorder, hypertension, muscle wasting and atrophy, schizophrenia, and bradycardia. R9's MDS (MDS/Minimum Data Set) dated 10/18/23 showed R9's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its isolation guidelines by cohorting isolation and non-isolation residents in the same room. The facility also failed to follow its standard precaution policy by not changing gloves and performing hand hygiene during incontinence care and when leaving an isolation room. This applies to 5 of 5 residents (R18, R41, R54, R145, and R344) reviewed for infection control in a sample of 31. The Findings include: 1. R54 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. 2. R145 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. On 01/09/24 at 11:37 AM, V5 (Wound Care Nurse) stated, R54 has Methicillin-resistant Staphylococcus Aureus (MRSA) infection with his right stump. R145 is not in isolation. We are combining those residents because R54's stump wound is covered with a dressing and is contained. On 1/9/24 at 11:45 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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 provide dignity to 3 residents (R64) who was not properly clothed while in dining room, (R15) who's catheter bag was not covered, and in view of others, and (R16) who's shoes were not properly maintained and safe to wear in a sample of 31. Findings include: 1. On 01/09/24 at 12:27 PM, R64 was observed in the dining room with a hospital gown on. The gown was open in the back, and the gown was continuously falling in front. R64 kept having to pull up the gown while she tried to eat. R64 said that the staff had not changed her clothes for the day. On 1/9/24 at 12:27 PM, V7 (Memory Care Director/Certified Nurse's Assistant) said that R64 should not be in the dining room in a hospital gown, she should be fully dressed in day clothes. On 01/11/24 at 12:45 PM, V1 (Administrator/RN) said R64 should have been dressed in weather appropriate clothes that covered her, and that she wanted to wear. V1 said that R65 was not dressed appropriately because…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have an adaptive call light accessible for one resident and adaptive eating utensils for a dependent resident. This applies to 2 of 2 residents (R32 and R66) reviewed for accommodation of needs in a sample of 31. The findings include: 1. On 01/09/24 at 11:24 AM, R32 was sitting in a motorized wheelchair. R32's left arm was contracted to his chest. R32 was able to move his right arm. R32's thumb and fifth finger on his right hand was contracted in the downward position. R32's index, middle and ring fingers were in a straight position, and not able to move or flex. R32's left leg was contracted. R32 stated he needed to be repositioned. R32 attempted to press the call button in his room. R32 was unable to press the button due to the limited range of motion in both hands. The call light was pressed for R32 by the surveyor. On 01/10/24 at 12:10 PM, R32 still did not have the appropriate call light for him to use. R32 said he informed the staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to provide non slip footwear to residents at high risk for falls. This applies to 2 of 2 residents (R50 and R75) reviewed for falls in a sample of 31. Findings include: 1. On 01/09/24 at 11:20 AM, R50 was observed in the dining room and hallway with no shoes or non-slip socks on. V14 CNA (Certified Nurse's Assistant) said she was R50's CNA for the day and she did not pay attention to her socks that she was wearing on this day. V14 said that they were the socks that R50 went to bed in the night before. On 01/09/24 at 11:23 AM, V7 (Memory Care Coordinator/CNA) said she had put R50's shoes under the storage unit in the dining room because R50 had taken them off. She said that around 10:45 am, she attempted to put R50's shoes back on her but R50 took them back off. V7 said she could have put on non-slip socks on R50, but she didn't do it because she knew R50 was going to get a shower that day. V7 said that she should have put on non-slip socks…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
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 humidification with oxygen therapy. This applies to 2 of 3 residents (R39 and R87) reviewed for oxygen therapy in a sample of 31. The findings include: 1. R39 is a [AGE] year-old male admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS) dated [DATE]. Record review on R39's Physician Order Sheet (POS) for 01/2024 documented oxygen therapy with nasal cannula at 2-3 liters per minute (L/M) and to change oxygen tubing and water bottle every week and as needed. On 1/9/23 at 11:04 AM, R39 was on his bed with a Nasal Cannula with no water in the humidifier bottle. R39 stated, My nose is dry, and it's better to have some water with a humidifier. 2. R87 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the MDS dated [DATE]. On 1/9/23 at 10:42 AM, R87 was in his wheelchair with a Nasal Cannula with no water in the humidifier bottle. On 01/09/24 at 11:32 AM, V8 (Nurse) stated, The nurses…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-04-06 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 4 of 4 residents (R27, R41, R47, R74) reviewed for ADL (activities of daily living) in the sample of 20. The findings include: 1. R41 has multiple diagnoses which includes cerebral infarction, type 2 diabetes mellitus, generalized muscle weakness, and muscle wasting and atrophy, based on the face sheet. R41's quarterly MDS (minimum data set) dated January 4, 2023 shows that the resident is moderately impaired with cognition and required extensive assistance from the staff with most of his ADLs including personal hygiene. On April 3, 2023 at 11:48 AM, R41 was in bed, alert and verbally responsive. R41's blanket that was covering the resident had a big brown stain. R41 stated that he spilled something from breakfast and wants to have his blanket changed. R41's fingernails were short but with accumulation of black substances underneath. R41 stated that 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.
- Potential for harm · Ecited before2023-04-06 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent urinary tract infection (UTI) and failed to provide and maintain indwelling urinary catheter care. This applies to 4 of 4 residents (R11, R12, R55, R79) reviewed for incontinence and catheter care in the sample of 20. The findings include: 1. On 4/05/23 at 11:11 AM, V15 and V17 (Both Certified Nursing Assistants/CNA) entered R11's bedroom to render incontinence care. V15 and V17 donned PPE (personal protective equipment) such as gown and gloves. V15 stated that R11 is on contact isolation for ESBL (Extended-spectrum Beta-lactamases) in the urine. On 4/05/23 at 11:15 AM, V15 and V17 (Both Certified Nursing Assistants/CNA) rendered incontinence care to R11 who was wet with urine. V15 wiped R11's outer labia with wet washcloth, however he did not separate the labia to clean the inner folds. V15 and V17 assisted to position R11 on her left side then V15 proceeded to clean buttocks but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-04-06 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure 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 lunch meal. This applies to 8 of 8 residents (R15, R35, R53, R54, R62, R69, R246, R248) reviewed for pureed diets in the sample of 20. The findings include: On April 4, 2023 at 11:30 AM, inside the kitchen, V10 (Dietary aide) placed 10 scoops (using scoop size #12 equivalent to 1/3 cup) of the facility prepared and cooked chicken enchilada inside a metal pan. V10 stated that the cook will puree the 10 scoops of the chicken enchilada for the lunch meal. At 11:36 AM, V11 (Cook) was observed preparing to puree the lunch meal. V11 used the chicken enchilada that was earlier measured and placed inside a metal pan by V10. V11 placed the chicken enchilada inside the food processor, added 2.5 tablespoons of thickener into the same food processor and started to puree the mixture. V11 then opened the food processor cover, placed the pureed chicken enchilada mixture inside the metal pan and stated that the chicken enchilada mixture is ready to be served…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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
Based on observation, interview and record review the facility failed to assess and provide adaptive equipment to a resident, to prevent further reduction in mobility and ROM (range of motion). This applies to 1 of 5 residents (R67) reviewed for limited range of motion in the sample of 20. The findings include: R67 has multiple diagnoses which includes cerebral infarction due to thrombosis of other precerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, generalized muscle weakness and aphasia, based on the face sheet. R67's quarterly MDS (minimum data set) dated February 9, 2023 shows that the resident is severely impaired with cognitive skills for daily decision making. The MDS showed that R67 required extensive assistance from the staff with most of his ADLs (activities of daily living). The same MDS showed that R67 had functional limitation in range of motion to one side of both his upper and lower extremities. On April 3, 2023 at 11:32 AM, R67 was in bed, alert but non-verbal. R67's right arm and hand was observed positioned on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-04-06 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 related to hand hygiene and change of gloves during provisions of care. This applies to 2 of 20 residents (R11, R79) reviewed for infection control during provisions of care in the sample of 20. The findings include: 1. On 4/05/23 at 11:11 AM, V15 and V17 (Both Certified Nursing Assistants/CNA) entered R11's bedroom to render incontinence care. V15 and V17 donned PPE (personal protective equipment) such as gown and gloves. V15 stated that R11 is on contact isolation for ESBL (Extended-spectrum Beta-lactamases) in the urine. On 4/05/23 at 11:15 AM, V15 and V17 rendered incontinence care to R11 who was wet with urine. V15 cleaned V11 from front to back of the perineum. While wearing the same soiled gloves, V15 applied barrier cream to R11. After V15 applied the barrier cream, he changed his gloves and without performing hand hygiene he applied clean incontinence brief. Then V17 took the soiled incontinence pad and continued to straighten R11's clean beddings while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CITADEL HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 4 of 5 | 3.5 | +0.5 vs chain |
| Staffing | 2 of 5 | 1.8 | +0.2 vs chain |
| Quality measures | 2 of 5 | 3.4 | -1.4 vs chain |
The other 13 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| GRAF, MARCELLA | Individual | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/15/2023 |
| GROSS, SHOSHANA | Individual | DIRECT OWNERSHIP INTEREST | since 12/15/2023 |
| KOHEN, YAKOV | Individual | DIRECT OWNERSHIP INTEREST | since 12/15/2023 |
| KROLL, GABRIEL | Individual | DIRECT OWNERSHIP INTEREST | since 12/15/2023 |
| NAGEL, STEVEN | Individual | DIRECT OWNERSHIP INTEREST | since 12/15/2023 |
| OLLMAN, JONATHAN | Individual | DIRECT OWNERSHIP INTEREST | since 04/01/2023 |
| PROCTOR, KATHERINE | Individual | DIRECT OWNERSHIP INTEREST | since 12/15/2023 |
| TELLER, ILANA | Individual | DIRECT OWNERSHIP INTEREST | since 12/15/2023 |
| AARON, JONATHAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/15/2023 |
| ADAMS CARR, MACAELA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/31/2024 |
| ROBIN, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2024 |
| BERGER, MENACHEM | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/07/2025 |
| ISRAEL, BENJAMIN | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/07/2025 |
| STERN, TODD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/07/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 16% 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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145043. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-11-22, 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 →
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