Tri-State Village Nrsg & Rhb

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

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

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

Staffing

How full it usually is: this home is certified for 84 beds and averages 79.4 residents a day — about 95% occupied, or roughly 5 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 3.29 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.69 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 2.82 hrs/resident/day on weekends vs 3.48 on weekdays — 19% thinner on weekends. RN hours go from 0.93 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% 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.

54 citations, most serious first. The 21 most serious are shown; the remaining 33 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision to a cognitively impaired resident and provide adequate monitoring of exit doors. This failure affected one of three residents (R1) reviewed for elopement in a sample of three. This failure resulted to an Immediate Jeopardy. The Immediate Jeopardy began on 04/14/2025 at 2:30PM when R1 exited through the locked dining room door without the door alarm going off, went to the patio/courtyard, exited the patio/courtyard gate, and did not come back. V2 (Director of Nursing) and V3 (Assistant Administrator) were notified of the Immediate Jeopardy on 04/18/2025 at 2:18PM. The facility presented an acceptable removal plan, and the immediacy was removed on 04/23/2025. The surveyor conducted an onsite investigation on 04/23/2025 to confirm the removal plan was implemented. V1 (Administrator) was informed that the Immediate Jeopardy was removed on 04/23/2025. Although the immediacy was removed, the facility remains out of compliance at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-03-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess, monitor and treat residents with multiple pressure ulcers for 2 of 3 residents (R3 and R4) This deficient practice resulted in R3 being hospitalized for necrotizing fasciitis of the wound bed. Findings include: On 3/10/2026 at 2:00pm V14(Certified Nursing Assistant-CNA) said on 10/5/2025 she entered R3 room and V10 said to clean her up she's going out to the hospital the areas on her buttocks were some what dark she did answer me correctly when I told her what I was doing she responded ok. R3 could not turn or reposition herself she was dependent on staff for all care. On 3/10/2026 at 3:00pm V8(Nurse Practitioner-NP) said that a wound can become infected with necrotizing fasciitis leading to sepsis based on three of the five criteria that the hospitals use, tachycardia, fever, increased white cells, infected wounds, disease factors, V8 said she did not observe R3 wound on 10/5/2025 she gave order to send her out because of a new…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-11-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, this facility failed to provide the necessary care and services to prevent a stage 3 sacral pressure ulcer from recurring, assess and document wound conditions, perform weekly wound assessments with measurements for one resident (R1) out of three residents reviewed for pressure ulcers. On 10/1/25 R1's stage 3 sacral pressure ulcer reopened; wound measured 2.9cm (centimeters) x 0.6cm x 0.1cm. On 11/14/25, R1's wound declined; wound measures 3cm x 4,3cm x 0.4cm with 50% slough and 50% granulation tissue. Findings include:On 11/17/25 at 8:45 AM, V4 (wound care nurse) stated that she believes R1's sacral pressure ulcer is facility acquired. V4 stated that the nurse is expected to chart in the resident's medical record when dressings changed. V4 stated that resident's family is updated weekly after resident is seen by wound care physician. V4 stated that the resident's family is notified if a new wound identified. V4 stated that wounds are measured weekly during wound care physician rounds. V4 stated that if resident develops a MASD…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-04-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, observations, and records reviewed the facility failed to identify and evaluate nutrition interventions for one resident. This affected one of one resident R2 reviewed for nutrition in sample of 72. This failure resulted in R2 having a significant unplanned weight loss of 16.7% in 4 months. The findings include: R2 is alert but has diagnosis including but not limited to Dementia, Major Depressive Disorder, Schizoaffect Disorder, Restless and Agitation, and Pseudobulbar Affect. R2 is difficult to understand his words. 04/27/25 10:08 AM R2 observed eating in bed, head of bed elevated, tray table over him, food spilt along left side of chest, leaning towards left in bed. Food cover, milk carton, and food debris on the floor along left side of bed. On 04/28/25 at 12:59 PM R2 in bed, feeds self in bed. R2 said he prefers to stay in his room. On 4/30/25 at 12:17 V26, Dietary Manager, said Restorative department does weights and enters it in the resident records. V26 said I do a review of re-weights. V26 said after the re-weight we notify the Registered Dietician 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
• Actual harm · Gcited before2024-08-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to develop an effective plan with interventions to prevent or reduce the risk of falling for a resident diagnosed with Dementia, wandering behaviors and identify as a high fall risk with balance problems while standing. This affected one of three residents reviewed for falls and fall prevention. This failure resulted in R2 having eight falls, seven of which were unwitnessed and one fall resulting in right periorbital soft tissue swelling and right scalp hematoma with contusion of face and scalp. Findings Include: R2 was diagnosed with Dementia, lack of coordination and need for assistance with personal care. R2's Fall risk observation dated 4/10/24 documents: disoriented times three (person, place, and time) and balance problems while standing, high risk. R2's Care Plan dated 4/12/24 documents: R2 presents with wandering behaviors. Wandering with or without a purpose. R2 was risk for falling related to Dementia, weakness, and history of falls. On 8/10/24 at 2:07pm, V2 (restorative nurse) stated, R2 had a fall in the dining…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide, evaluate, and reevaluate the effectiveness of the motorized wheelchair safety/training/education to reduce the risk of injuries for one resident. This affected one of one resident (R1) reviewed for safe use of the motorized wheelchair. This failure resulted in R1 having multiple accidents attempting to maneuver the wheel motorized wheelchair. R1 sustained a fractured toe, and a laceration to the leg requiring 6 sutures. Findings include: On 6/18/24 at 11:11am R1 observed sitting in motorized wheelchair, R1 escorted to room for interview and observation assisted by V16 Licensed Practical Nurse (LPN). R1 observed alert with confusion. R1 observed to have healing scar to left lower leg. R1 was not able to recall what happened to her leg. R1 stated her toes were broken when the door hit her foot, R1 stated she was on her way out the room when the door hit her foot. R1 stated her feet were not on the footrest, (R1 demonstrated that her feet were 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records reviewed the facility failed to conduct a thorough investigation to explain the origin of bruising for one resident. This affected one of three residents (R5) reviewed for injury of unknown origin. This failure resulted in unexplained black and blue bruising to R5's face and R5 being sent to the local hospital ICU/intensive care unit for treatment. The findings include: R5's diagnosis include but are not limited to Hemiplegia and Hemiparesis following other Cerebrovascular Disease, Dementia, Palliative Care, Contusion of Scalp, Subsequent Encounter, and History of falling. On 1/31/24 at 12:02 PM V9, Certified Nursing Assistant, said when I did rounds R5 was on the floor maybe around 9:40 PM. V9 said I asked R5 what happened and she gestured, V9 demonstrated a gesture, that she rolled out of bed. V9 said R5 was on her right side, and she was close to the bed. V9 said R5 looked like she just slipped out of bed, her legs were still on the bed, and her top half was on the floor. 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed follow physician orders for the administration of IV/intravenous medication and obtaining lab blood draw. This failure affected two of three residents (R12, R15) reviewed for physician orders. This failure resulted in R12 not receiving the IV medication for approximately 9 days being sent to the hospital after a change in condition. R12 was diagnosed and treated at the hospital for Sepsis and UTI (urinary Tract Infection). Findings include: 1. R12's face sheet shows diagnosis of dementia. R12's hospital records dated 11/17/23 denotes in-part clinical impression sepsis, UTI, hypernatremia, encephalopathy acute, pulmonary, hypokalemia. Blood culture gram positive bacilli. [AGE] year-old female presents ER/emergency room from nursing home for altered mental status. She is tachycardic. She apparently was just diagnosed with UTI She is septic from a UTI. She was given 30 cc/kg fluid bolus. She was also given Vanco Zosyn initially, meropenem. IV potassium…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-12-06 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  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 honor a resident's request to obtain assistance in obtaining the legal and/or social services necessary to have his guardianship status legally re-evaluated and maintain his highest practical well-being. This failure affected one (R1) of one resident reviewed for resident rights and has resulted in R1 suffering psychosocial harm as a result of not being able to leave the facility on pass status and having his phone taken away; this was further exhibited by R1 calling the police due to feelings of imprisonment. Findings include: R1 is a [AGE] year-old male who originally admitted to the facility on [DATE] with multiple diagnoses including but not limited to the following: hemiplegia, CHF, seizures, HTN, and CAD. Minimum Data Set (MDS) assessment dated [DATE] from admission shows that R1 had a Brief Interview of Mental State (BIMS) of a 14, indicating resident was cognitively intact. Most recent MDS assessment dated [DATE], shows R1 has 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-10-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record review, the facility failed to follow prevent a staff to resident incident of abuse. This affected one of three residents (R1) reviewed for abuse. This failure resulted in R1 diagnosed with dementia being involved in a verbal altercation with staff which escalated to V3 throwing a meal tray at R1. Using the reasonable person concept would cause R1 to be fearful of V3's impulsive and abusive behavior. Findings Include: Initial State Agency reportable, reads in part: with occurrence date of 9/28/23. Family member of another resident reported to the nurse that they observed an activity aide throw food at the resident. Nurse immediately provided for safety and redirected the activity aide away from residents and contacted administrator. Nursing performed head to toe assessment with no noted injury or skin alteration. R1 denied any pain or distress. Occurrence resolution: R1 denied event. During interview, V3 acknowledged that he did upend food on tray into R1's lap as a reaction. Allegation is substantiated. V3 employment terminated. Police report dated…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-01-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow its policy related to documentation, monitoring and physician notification related to bowel movement for one (R26) of three residents reviewed for quality of care. This deficiency resulted in R26 complaining of constipation for several days before being sent to the emergency room for further evaluation and subsequently found to have fecal impaction in the rectum. Findings include: R26 is a [AGE] year-old, female, admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, morbid obesity due to excess calories and other sequelae of cerebral infarction. On 01/17/23 at 12:30PM, R26 was asked about her recent hospitalization. R26 stated, It was five or six days that I did not move my bowels. I told staff that I cannot move my bowels and I was having abdominal pain. They are giving me Miralax (Polyethylene Glycol, laxative) every day, but it did not…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-13 · 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 ensure a resident with a history of falls was monitored during a transfer for one of three residents (R2) reviewed for falls. Findings Include:On 3/10/2026 at 1:30pm R2 said that on 3/3/2026 , his CNA sat him up on the side of the bed, went to retrieve the mechanical lift he could not hold his balance and slid to the floor. On 3/11/2026 at 12:58pm , V14(Certified Nursing Assistant-CNA) said she sat R2 on the side of the bed and went to retrieve the mechanical lift R2 yelled, she ran over to him and lowered him to the floor then went for assistance. On 3/12/2026 at 11:30am, V12(Restorative Nurse/Fall Coordinator) said R2 is a high risk for falls and should not be left alone on the side of the bed. On 3/12/2026 at 2:00pm, V2(Director of Nursing-DON) said I expect the staff to monitor any resident that is high risk for falls and never leave them alone on the side of the bed. A resident face sheet indicates R2 has a diagnosis of dementia, Parkinson's disease, edema unspecified of BLE-Bilateral lower extremities unspecified…

  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 · F2025-08-27 · tag F0940 — failed to train staff — widespread
  Develop, implement, and/or maintain an effective training program for all new and existing staff members.
  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 follow their policy and facility assessment and assure competency of each employee for proper transferring technique to safely transfer residents. This includes gait belt use training for all nursing staff and mechanical lift training for 7 Certified Nursing Assistants. This failure affected one resident R3 and has the ability to affect all 76 residents in the facility.Findings include:R3 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: Paraplegia, Multiple Sclerosis, and morbid obesity.R3's Minimum Data Set (MDS) dated [DATE] section C0500 documents Brief Interview for Mental Status (BIMS) score = 15 which suggests cognition is intact. Section GG0130 documents resident needs set up or clean up assistance for eating. Resident needs partial/moderate assistance for upper body dressing. Resident needs substantial/maximal assistance for oral hygiene, shower/bathe self, lower body dressing, and…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-27 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to transfer a resident safely and in line with facility protocols, which resulted in R3 falling while staff were transferring R3 from the chair to bed. This failure applied to one (R3) of four residents reviewed for falls.Findings include:R3 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: Paraplegia, Multiple Sclerosis, and morbid obesity.R3's Minimum Data Set (MDS) dated [DATE] section C0500 documents Brief Interview for Mental Status (BIMS) score = 15 which suggests cognition is intact. Section GG0130 documents resident needs set up or clean up assistance for eating. Resident needs partial/moderate assistance for upper body dressing. Resident needs substantial/maximal assistance for oral hygiene, shower/bathe self, lower body dressing, and personal hygiene. Resident is dependent on staff for toileting hygiene and putting on/taking off footwear.On 8/11/2025, at 10:56 AM, R3 stated I did have 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-30 · tag F0755 — failed to provide safe pharmacy services — pattern
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure they had insulin pen needles for resident's insulin administration for (R5, R28, R54, R55) four of four residents reviewed for pharmaceutical services. Findings include: R5 R5 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with other circulatory complications. R5s physician order sheet dated 9/5/ 24 documents: lantus (glargine) solostar insulin pen. Inject 40 units subcutaneously daily. R5's insulin medication administration record for April documents R5 was administered lantus insulin for the month of April. On 4/29/25 at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that R5 had lantus insulin pen with no insulin vials observed. On 4/28/25 at 12:50PM, V31 (Nurse) said he has been working at the facility for the last three weeks and they have not had any pen needles for the insulin pens. V31 said he informed facility staff, but they never received any. V31 said he still…

  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 · Ecited before2025-04-30 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow their medication labeling, Storage of medications and insulin administration policies by not discarding expired insulin and eye drops, ensuring open date and expiration dates were labeled on insulin pens, and ensuring all insulin pens were labeled with residents name for four ( R5, R54, R64, R67) of four residents reviewed for medication storage. Findings include: R5 was admitted to the facility on [DATE] with a diagnosis of type II diabetes with other circulatory complications. R5s physician order sheet dated 9/5/ 24 documents: lantus (glargine) solostar insulin pen. Inject 40 units subcutaneously daily. R5's insulin medication administration record for April documents R5 was administered lantus insulin for the month of April. On [DATE] at 10:43AM, Surveyor observed west medication cart with V17(nurse). V17 confirmed that R5 had lantus insulin pen with no insulin vials observed. There was no open or expired dates labeled on 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-30 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  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 shower room water was within normal temperature range between 100 -110 degree (fahrenheit) for one of two shower rooms. This failure has the potential to affect all 52 residents on the shared unit. Findings include: On 4/30/25 at 10:35AM, East/west shower room water temperature was checked with V16(maintenance director). V16 said the thermometer which was an infrared device did not need to be calibrated and was working properly at time of observation. Shower water temperature was temping between 80-82 degrees Fahrenheit. On 4/30/25 at 10:33AM, V16(maintenance director) said they had an issue with hot water tank sometime this month and parts were replaced. V16 said it affected the east/west shower room. V16 denied any current concerns with shower rooms or receiving any concerns related to the shower room temperatures. V16 said the shower temperature was checked this morning with no issue or concern. Facility water temperature log for April 2025 does not document any shower room temperatures taken.…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-04-30 · tag F0947 — failed to train nurse aides adequately — pattern
  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and records reviewed the facility failed to provide staff with training for dementia care and cognitively impaired residents. This failure has the potential to affect 42 residents with diagnosis of Dementia or Cognitive Impairments in the facility, in a sample of 72 residents. The findings include: The facility presented Dementia & Alzheimer's Caregiving Post Test for 3 CNAs. V18 and V19 test are dated 8/9/23 and V20 is dated 9/28/23. On 4/29/25 at 12:37PM V3, Assistant Administrator, said we don't have any training for the CNAs for 2024 to including Dementia training or Care for Cognitive Impairments. The facility In service Training Program, Nurse Aid, undated, states annual in-service must ensure continuing competence of nurse aides, be no less than 12 hours per employment year, address the special needs of the residents with cognitive impairment. Enhance the skills of the nurse aids in providing care for residents with Dementia. All trainina attendance will be entered on the Employee Trainina Attendance Record. Records shall be filed in the employee'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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-04-30 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and records reviewed the facility has not obtained a new PASSAR for a resident with onset of symptoms and diagnosis of Bipolar Disorder. This affected one of four residents (R4) reviewed for PASSARs in a sample of 72 residents. The findings include: R4's PASSAR on file dated 2/25/25 states no level II needed and no specialized services. R4's diagnosis include, but are not limited to Spina Bifida, Bipolar Disorder, Current Episode Mixed, Sever With Psychotic Features, Suicidal Ideations, Hereditary Spastic Paraplegia, and Major Depressive Disorder. On 04/29/25 at 11:07 AM V7, Social Services, said I know when the residents need a new PASSAR because I check the website often (Maximus). R4 is not showing up. On 04/29/25 at 1:41 PM V7 said Resident # 4 he expressed to the Nurse Practitioner that he had felt some kind of way, when I spoke to him he denied it. V7 said we sent him out anyway. V7 said I did not submit for a new PASSAR, I probably should have. Progress notes dated 3/13/25 state R4…

  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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide 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 interviews and records reviewed the facility failed to offer showers for two (R60 and R5) of four residents in a sample of 72 reviewed for ADL assistance. The findings include: On 4/28/25 at 1:53PM the surveyor checked the 2 facility shower rooms. South hall shower room had dry floor. The shower faucet was dry. The surveyor then checked the East/West shared shower room, upon entering the room, there was a foul odor and the bath tub was full of dead, winged, bugs. The shower area floor was dry and the shower head was dry. No drops of water were seen in the only two showers of the facility. On 4/28/25 at 2:02PM V8, Restorative Nurse, toured the south shower room with the surveyor. The floor was wet, but a housekeeper was in the room and said he just wet it. V8 said it's wet because I just wet it, it was dry. V8 and surveyor then checked East/West shower. V8 said I would not want to shower in here, there is a smell. V8 said it does not appear this shower was used, it is dry. V8 said she has worked in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to transcribe and initiate a verbal order by not ordering an ultra sound as requested by the nurse practitioner for one of one residents (R30) review for quality of care in a sample of 72. Finding Includes: R30's brief interview for mental status dated 4/22/25 documents a score of fifteen which indicates cognitively intact. Nurse Practitioner progress note dated 4/25/25 documents: infected cyst to right side of neck: Assessment and Plan: Local infection of skin and subcutaneous infection - R30 has a sebaceous cyst but it was noted today that cyst is reddened and swollen. Progress Note dated 4/25/25 documents: Writer (V11) notified by staff member of large bump on patients neck. Writer went to assess and observed large abscess on right side of patient's neck. Assess is tender to touch and painful. Patient describes pain level at a 5 when assess is touched. NP made aware, N/O (new order) for antibiotics and ultrasound of neck. On 4/27/25 at 1:13pm, R30 was observed with a golf ball size lump with a white circular area the size…

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

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

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

Fines & penalties

$279,810 in federal fines across 5 penalties. 3 Medicare payment denials on record.

• $50,915 — penalty dated 2026-03-13
• $46,900 — penalty dated 2025-11-17
• $23,651 — penalty dated 2024-06-28
• $52,858 — penalty dated 2024-02-09
• $105,486 — penalty dated 2023-09-05
• Medicare payment denial — starting 2025-05-14 for 16 days
• Medicare payment denial — starting 2024-07-30 for 30 days
• Medicare payment denial — starting 2023-11-09 for 51 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ATIED ASSOCIATES — 12 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 7 rows in the source record cover these 5 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.

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.

About 91% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $395K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

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

What families pay in IL