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Cedar Ridge Health & Rehab Ctr

One Perryman Street, Lebanon, IL 62254 · For profit - Corporation · 116 certified beds · (618) 537-6165 Medicare & Medicaid certified

Call the home — (618) 537-6165 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 actual-harm citations
Insights

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

In its favor
  • a 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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (59%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
110 W St Louis St · (618) 537-4407 · Call to confirm hours
Pharmacy
753 True Value Dr · (618) 537-6202 · Call to confirm hours
Grocery
720 W McAllister St · (618) 537-6121 · Call to confirm hours
Park
11109 Widicus Rd · (618) 566-4027 · Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 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 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.5%13.4%15.4%better
Long-stay residents who lose too much weight6.8%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.9%0.9%better
Long-stay residents with a urinary tract infection0.9%1.5%2.0%better
Long-stay residents with depressive symptoms87.2%54.2%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.0%3.1%3.3%better
Long-stay residents whose ability to walk worsened8.1%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.8%18.3%18.9%typical
Long-stay residents given the seasonal flu vaccine98.0%91.8%95.3%typical
Long-stay residents with pressure ulcers3.7%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control26.3%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.2%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication2.5%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine85.7%63.1%79.4%typical
Short-stay residents rehospitalized after admission20.9%26.1%22.6%typical
Short-stay residents with an outpatient ER visit11.0%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days2.032.021.67worse
Long-stay outpatient ER visits per 1,000 resident days2.272.221.80worse

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.

48.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.6%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
51.7%U.S. median 56.6%
Met the expected recovery
0.31U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 51.7% 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 60 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF48.6%CMS range 38.0–59.651.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 8.2–14.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge51.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge45.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge43.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.2%CMS range 4.7–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.101.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.78
RN hours/ resident / day
0.43
LPN hours/ resident / day
1.91
Aide hours/ resident / day
3.12
Total nurse hours/ resident / day
0.49
RN hoursweekends
59.1%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 116 beds and averages 106.7 residents a day — about 92% occupied, or roughly 9 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 3.12 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 1.91 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 2.52 hrs/resident/day on weekends vs 3.37 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.91 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2026-03-12)
11
at the previous standard inspection (2025-01-30)

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

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

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

20 citations, most serious first. The 12 most serious are shown; the remaining 8 are one tap away and print in full.

  • Actual harm · G2025-01-30 · tag F0697 — failed to manage pain — isolated
    Provide 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 interview, observation, and record review the facility failed to provide effective pain management for 1 (R10) out of 1 resident reviewed for pain in the sample of 44. This failure resulted in R10 experiencing ongoing pain during peri-care as evidence by visual and audible reports of pain expressed. Findings include: R10 was readmitted to the facility on [DATE] from the hospital with diagnosis of, in part, surgical aftercare on the digestive system, calculus of bile duct with cholecystitis, biliary acute pancreatitis, acute and chronic respiratory failure, and transient cerebral ischemic attack. R10's Minimum Data Set (MDS) dated [DATE], documented she is moderately cognitively impaired, is depended on staff for toileting hygiene, lower body dressing, rolling left and right, siting to standing and all types of transfers. R10's MDS further documented she required partial/moderate assistance from staff for personal hygiene and required substantial/maximal assistance from staff with showering/bathing.…

    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 · G2023-08-11 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services 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 interview, observation, and record review the facility failed to ensure that residents who require Dialysis received such services, consistent with professional standards of practice for 2 out of 3 residents (R1, R2) in a sample of 3. This failure resulted in R2 having to be sent to the emergency room and admitted with fluid overload. Findings include: 1.) R2's Physician Order (PO) dated 07/13/23 documents Chronic combined systolic (congestive) and diastolic (congestive) heart failure, type 2 Diabetes Mellitus with diabetic chronic kidney disease, End stage renal disease, and dependence on renal dialysis. R2's PO dated 08/09/23 documents Dialysis - FYI - Dialysis Treatments 3 X Week at 2:45 PM At: (local dialysis center) Every M-W-F. R2's Care Plan dated 08/08/23 documents, Hemodialysis r/t End Stage renal failure. R2's MDS (Minimum Data Set) dated 07/20/23 documents that resident has no cognitive impairment. The MDS documents that R2 requires extensive assistance of one person for dressing, toilet use,…

    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 · F2026-03-12 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to document when a multi use vial of Aplisol (Tuberculosis/TB testing solution) was opened. This has the potential to affect all 106 residents in the facility.Findings include:On 3/10/2026 at 12:04 PM the facility's medication storage room was observed with V27 (Licensed Practical Nurse/LPN). V27 pulled an opened bottle of Aplisol from the medication refrigerator. There was no date documented on the bottle or packaging that documented when the bottle was open or when it would expire. V27 stated she did not know when the bottle was first opened.The medication label on the bottle of Aplisol states Refrigerate. Protect from light. Discard in use vial after 30 days. V27 states that this entire facility would use this medication.On 3/12/2026 at 9:54 am V11 (Wound Nurse) who states she is covering for the Director of Nursing in her absence, stated that multi use vials including TB solution should be dated when they are opened.The facility's policy, Medication Storage, revised on 8/23/22, documents the facility stores…

    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 · Fcited before2026-03-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain Sanitary conditions in the kitchen to promote safe food handling. This failure has the potential to affect all 106 residents residing in the building.The findings include: On 3/9/26 at 10:45 AM, during the lunch observation, V7 (Cook), and V8 (Cook) were seen serving food from the steam table onto plates, then placing the plate on a tray which was delivered to the residents. Directly above the steam table of food, there was a ceiling vent with vents that were pointed down towards the food. The vent itself, the ceiling around the vent, the light close to the vent, and the adjacent wall by the vent was dirty with a lot of greasy dirt and/or lint seen. This vent blows air down onto the steam table with potentially the dirt/lint falling onto food items and being served to the residents.On 3/11/26 at 3:15 PM, V4 (Dietary Manager) stated I don't have any cleaning logs. I just tell V22 (Dietary Aide) to clean the walls about once a week.On 3/11/26 at 3:17 PM, V22 (Dietary Aide) stated I just wiped down 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were safely transferred via mechanical lift, failed to ensure fall interventions were in place according to resident Care Plans, and failed to provide an appropriate shower chair resulting in a resident to sustain a fall for 4 of 7 (R22,R28, R54, R69) residents reviewed for accidents in the sample of 52. Findings Include:1.R28's admission Record print date of 3/11/26 documents R28 has diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, COPD (chronic obstructive disease), chronic atrial fibrillation, hypertension, polyneuropathy, depression, and anxiety. R28's MDS (Minimum Data Set) dated 1/19/26 documents R28 is cognitively intact and requires partial/moderate assistance with wheelchair transfers and showers. R28's undated Care Plan documents R28 is at risk for falls related to left hemiparesis, difficulty walking, and lack of coordination with a goal of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-12 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature for 6 of 10 residents (R9, R17, R20, R45, R58, R60) reviewed for palatable and appetizing food in the sample of 52.The findings include: 1. R45's admission Record, dated 3/11/26, documents R45 was originally admitted on [DATE]. R45's Minimal Data Set (MDS), dated [DATE], documents R45 is cognitively intact. On 3/9/26 at 1:03 PM, R45 stated the food is not good and sometimes warm, sometimes cold. 2. R58's admission Record, dated 3/11/26, documents R58 was originally admitted to the facility on [DATE]. R58's MDS, dated [DATE], documents R58 has a moderate cognitive impairment. On 3/9/26 at 9:50 AM, there was contact and droplet isolation signs on R58's door. R58 stated he eats in his room and the food is terrible, taste like institutional food with no taste and is always cold by the time he gets it. 3. R60's admission Record, dated 3/11/26, documents R60 was…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for 2 of 8 residents (R93, R96) reviewed for incontinent care in the sample of 52.The findings include: 1. R93's admission Record, dated 3/9/26, documents R93 was originally admitted to the facility on [DATE] with diagnosis of Dementia, Cirrhosis of liver, Type 2 DM, Spondylopathies, Chronic Kidney Disease (CKD)-stage 3, HTN, Polyneuropathy, Uropathy, Anemia, Major depressive disorder, COVID, Osteoarthritis, and Neuralgia/Neuritis. R93's Care Plan, dated 3/3/26, documents R6 has an ADL (Activities of Daily Living) self-care performance deficit. Interventions: Bathing: Uses adaptive equipment Shower Chair/Bed with total assist but R93 prefers to have bed baths, Personal Hygiene: 1 person assist. 1/6/26: R93 is unable to dress or groom independently related to: Polyneuropathy, Lumbar Disc Degeneration, Polyarthritis. 2/6/26: R93 is at risk for impaired skin integrity related to confined to a bed…

    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 · E2025-01-30 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review, the facility failed to provide dignity during feeding assistance and ensure resident call lights are within reach of the resident for 4 of 20 residents (R8, R65, R93, R94) reviewed for resident dignity in the sample of 44. The Findings Include: 1. On 1/26/25 11:45 AM, V6 (Restorative Certified Nursing Assistant/CNA) was seen standing between R65 and R93 at a dining room table. V6 stood and used her right hand to feed R93, then used her left hand to feed R65. R65's Care Plan, dated 1/23/25, documents R65 has a Self-Care Deficit with Interventions: Take to dining room for meals, Eating - Setup help / Cueing required. R65's Minimum Data Set (MDS), dated [DATE], documents R65 is cognitively intact and is dependent on staff for eating. 2. R93's Care Plan, dated 11/4/24, documents R93 has Self-Care Deficit with Interventions: Eating - Independent required. R93's MDS, dated [DATE], documents R93 has a severe cognitive impairment and required partial/moderate 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 Interview, Observation, and Record Review, the Facility failed to provide feeding assistance to Activities of Daily Living (ADL) Dependent residents requiring feeding assistance for 4 of 8 residents (R11, R24, R37, R59) reviewed for feeding assistance in the sample of 44. The Findings Include: 1. On 1/26/25 at 11:45 AM, R24 was seen sitting at the dining room table with his lunch tray and was not touching his food. When asked about being the only staff member assisting residents, V6 (Certified Nursing Assistant/CNA) stated I usually have someone helping me but not sure where she is. R24 was just staring at his plate and did not pick up his fork to eat. V6 would see this and yell to R24, sitting at another table, to take a bite. R24's Care Plan, dated 11/8/24, documents R24 has Self-Care Deficit with Interventions: Eating - Setup help/Cueing required. R24's Minimum Data Set (MDS), dated [DATE], documents R24 has a moderate cognitive impairment and requires Supervision/Touching Assistance for eating. 2.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to supervise a resident with cigarettes, safely transfer residents using a mechanical lift, and implement fall interventions for 4 of 5 (R3, R41, R68, R94) residents reviewed for supervision. Findings include: 1. R41's Care Plan, dated 12/17/2024, documents that (R41) has Self-Care Deficit As Evidenced by: Needs assistance with ADLs Related to Parkinson's, chronic obstructive pulmonary disease (COPD), Chronic Respiratory Failure, Asthma, Interstitial Pulmonary Disease, Pulmonary Hypertension, Obstructive Sleep Apnea, Diabetes, end stage renal disease (ESRD), Hypertension, Congestive Heart Failure, Peripheral Vascular Disease, Hyperlipidemia, Anemia, Hypothyroidism, gastroesophageal reflux disease (GERD), Constipation, Convulsions, Morbid Obesity, Neuropathy, Gout, Arthritis, Left Above Knee Amputation, Right Below Knee Amputation, Low Back Pain, and incontinence. Transfer: Two-person physical assistance required Transfer: Mechanical Lift…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to do timely and complete incontinent care for 4 of 5 residents (R39, R41, R68, R79) reviewed for incontinent care in a sample size of 44. The Findings Include: 1. R79's admission Record, dated 1/27/25, documents R79 was originally admitted to the facility on [DATE] with diagnosis of Bipolar disorder, Depression, Hallucinations, Traumatic Brain Injury, Pancytopenia, Type 2 Diabetic Mellitus (DM), Thrombocytopenia, Urinary incontinence, Hydrocephalus, COVID, and Urinary Tract Infections (UTIs). R79's Care Plan, dated 1/30/24, documents R79 is incontinent of Bowel/Bladder. Interventions: Observe and record bowel and bladder pattern each shift, clean peri-area with each incontinence episode. It continues R79 has Self-Care Deficit as evidenced by: Needs assistance with Activities of Daily Living (ADLs) related to TBI, Obstructive Sleep Apnea, Diabetes, Tachycardia, Hallucinations, Bipolar Disorder, Depression, Pancytopenia, Thrombocytopenia, and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-30 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to serve food with an appetizing appearance and taste for 7 out of 7 residents, (R61, R10, R15, R2, R87, R53), reviewed for Nutritive Value/Appearance, Palatable/Preferred Temperature in a sample of 44. Findings include: 1.R61's Minimum Data Set (MDS) dated [DATE] documented she is cognitively intact. 1/26/25 at 9:35 AM R61 stated the food here is nasty, so I buy my own food to eat and have a refrigerator to keep it in. 2.R10's MDS dated [DATE] documented she is moderately cognitively impaired. 1/26/25 at 10:05 AM R10 stated the food is not good. 3.R15's MDS dated [DATE] documented she is cognitively intact. 1/26/25 at 10:11 AM R15 stated the food is not good and doesn't taste good, so I buy my own food and keep it in my personal refrigerator. 4.R2's MDS dated [DATE] documented he is cognitively intact. 1/26/25 at 9:30 AM R2 stated the food is grubby and doesn't look appetizing. 5.R87's MDS dated [DATE] documented he is cognitively intact.…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 8 citations
  • Potential for harm · Ecited before2025-01-30 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform hand hygiene and glove changes for 6 of 7 residents (R9, R27, R41, R65, R68, R93) reviewed for hand hygiene in the sample of 44. The Findings Include: 1. On 1/26/25 11:45 AM, V6 (Restorative Certified Nursing Assistant/CNA) was seen standing between R65 and R93 at a dining room table. V6 stood and used her right hand to feed R93, then used her left hand to feed R65. There was no hand hygiene seen done prior to or between assisting the residents. R65's Care Plan, dated 1/23/25, documents R65 has a Self-Care Deficit with Interventions: Take to dining room for meals, Eating - Setup help/Cueing required. R65's Minimum Data Set (MDS), dated [DATE], documents R65 is cognitively intact and is dependent on staff for eating. 2. R93's Care Plan, dated 11/4/24, documents R93 has Self-Care Deficit with Interventions: Eating - Independent required. R93's MDS, dated [DATE], documents R93 has a severe cognitive impairment and required…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-30 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    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 confirm the need for an antibiotic and failed to ensure a resident received all doses of the antibiotic(s) as ordered for 5 of 5 (R34, R39, R85, R89, R95) residents reviewed for the antibiotic stewardship program in the sample of 44. Findings include: 1. On 1/26/2025 the facility provided a document, not labeled, and not dated, listing Resident Name, DOB (date of birth ), Onset Date, Infection, and organism. On 1/28/2025 at approximately 2:00 PM V24 (Infection Preventionist) stated that this was the tracking tool used for infections and antibiotic usage. V24 stated that she was not sure what infection R39 had. The Facility's Infection Control Log, not dated, documents that R39 had an unknown infection starting 12/13/2024. The infection control log does not document if R39 received antibiotics, the residents medical record number, unit and room number, adverse effects, and outcomes. A review of R39's medical record was performed. No documentation of…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to follow wound care orders for 1 out of 1, (R87), reviewed for quality of care in a sample of 44. Findings include: R87 was admitted to the facility on [DATE] with diagnosis of, in part, chronic multifocal osteomyelitis of left ankle/foot, cellulitis, type two diabetes mellitus with foot ulcer and neuropathy, peripheral vascular disease and acquired absence of right leg above knee. R87's Minimum Data Set (MDS) dated [DATE], documented he is cognitively intact, requires substantial/maximal assistance from staff for lower body dressing, and is dependent on staff assistance for putting on/taking off footwear. R87's care plan dated 12/30/25 documented R87 has diabetic ulcers to the left heel and left dorsal mid foot relate to diabetes and lack of sensation to affected area. R87's interventions for the ulcers are documented as follows: Enhanced Barrier Precautions (EBP), Observe/document wound: Size, Depth, Margins: peri-wound skin, sinuses,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-30 · 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 observations, interviews, and record reviews the facility failed to provide treatment and services to prevent and/or heal pressure ulcers for 1 out of 1 resident (R10) reviewed for treatment/services to prevent/heal pressure ulcers in a sample of 44. Findings include: R10 was readmitted to the facility on [DATE] from the hospital with diagnosis of, in part, surgical aftercare on the digestive system, calculus of bile duct with cholecystitis, biliary acute pancreatitis, acute and chronic respiratory failure, and transient cerebral ischemic attack. R10's Minimum Data Set (MDS) dated [DATE], documented she is moderately cognitively impaired, is depended on staff for toileting hygiene, lower body dressing, rolling left and right, siting to standing and all types of transfers. R10's MDS further documented she required partial/moderate assistance from staff for personal hygiene and required substantial/maximal assistance from staff with showering/bathing. R10's Care Plan dated 11/19/24 documented R10 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
  • Potential for harm · D2025-01-30 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident is free from significant medication errors for 1 or 5 residents (R89) reviewed for medications in a sample of 44. Findings Include: R89's Face Sheet, original admission date of 10/04/24, documented R89 has diagnoses of but not limited to infection following a procedure, deep incisional surgical site, subsequent encounter, and local infection to the skin and subcutaneous tissue. R89's Minimum Data Set (MDS), dated [DATE], documented R89 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15 and is dependent on staff for transferring from bed to chair, chair to bed, and toileting transfer. R89's Care Plan, admission date of 12/26/24, documented R89 is at risk for complications related to (r/t) a wound infection and requires antibiotics. Interventions include but not limited to Administer antibiotic as per medical doctor (MD) orders. Follow facility policy and procedures for line listing, summarizing, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-02-15 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, observation, and record review, the Facility failed to ensure staff were wearing the appropriate Personal Protective Equipment (PPE) and following the required infection control practices. This has the potential to affect all 101 residents living in the Facility. Findings include: On 2/13/24 at 7:35 AM, the front door of the Facility had a sign documenting a current COVID-19 outbreak status. The Facility's Undated Covid Dates Report documented there were 12 residents being isolated for COVID-19 on 2/13/24. The Facility's Undated Covid Dates Report documented R7 and R8 were being isolated for COVID-19 on 2/13/24. On 2/13/24 at 7:43, the door to R7's and R8's room was standing wide open, and there was no isolation supply cart outside the room. On 2/13/24 at 7:50 AM, V5 (Certified Nursing Assistant/CNA) was walking through dining room during breakfast service with her N-95 mask worn below her nose. She pulled the mask up over her nose and stated the Facility does require staff to wear masks during the outbreak, and she was going to get her eye shield right then. On…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the Facility failed to prepare, and serve food in a manner which prevents potential contamination. This has the potential to affect all 100 residents living in the Facility. Findings Include: On 1/2/23 at 9:00 AM, during the initial tour of the kitchen, the ice machine did not have an air gap. On 1/2/23 at 9:05 AM, V23 (Dietary Manager) stated, It's a new ice machine. I will call maintenance to look at it. We fill all the drinks from that machine and put food on ice. On 1/2/23 at 11:00 AM, the tray line was observed. The meal was taco salad, and the lettuce was on the steam table. Temperatures were taken of the last tray to come off the tray line. The hamburger was 135 degrees Fahrenheit, the refried beans were 135 degrees Fahrenheit, and the lettuce was 70 degrees Fahrenheit. On 1/5/23 at 1:19 PM, V23 (Dietary Manager) stated that he had it (the lettuce) on the steam table to build the taco salad quicker and that he had it (the lettuce) on ice. The Facility policy Quick Resource Tool: Safe Food Handling documented, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-05 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 obtain laboratory results documenting the organisms being treated prior to initiating and/or continuing antibiotic therapy for 3 of 23 residents (R69, R91, R94) reviewed for antibiotic stewardship in a sample of 41. Findings include: 1. R69's Face Sheet, undated, documented that she was admitted to the facility on [DATE] from an area hospital. R69's Nurse Progress notes, dated 11/28/23, documented that the hospice nurse placed R69 on an antibiotic, due to her urine had changed in character and resident had some pain related to having a catheter. No laboratory work was ordered. R69's Physician Order Summary, undated, documented an order Sulfamethoxazole-Trimethoprim 800-160 milligrams (mg) for 10 days with a Start Date 11/28/23. R69's Hospital Lab results, dated 12/8/23, documented, R69's urine specimen was setup for culture but there were no results documenting that the culture and sensitivity were received. R69's Physician Order Summary, undated,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

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

RatingThis homeChain avg
Overall 3 of 52.2+0.8 vs chain
Health inspection 4 of 52.9+1.1 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 3 of 53.0≈ chain avg
The other 10 homes this chain runs (chain average 2.2★, 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 / managerTypeRoleSince
CREST CRJS HOLDCO LLCOrganizationDIRECT OWNERSHIP INTERESTsince 03/14/2025
IL M TRUSTOrganizationINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 03/14/2025
MRS WINDY CITY STATE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 03/14/2025
CAPITAL FINANCE LLCOrganization5% OR GREATER SECURITY INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
LICHTMAN, SHALOMIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2019
LIGHT MAN LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/14/2025
LTC CONSULTING SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2019
FLICK, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/06/2024
O'NEAL, KENYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/31/2023

CMS files one row per role, so the 15 rows in the source record cover these 9 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.

6 organizational owners 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.

$11.1M
Net patient revenuemost recent cost report
-11.8%
Operating marginrevenue minus expenses
$1.9M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 62%Medicare 8%Other / private 30%

This home reported $1.9M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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. 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

$340per resident / day
operating cost
$10,335per month
≈ monthly operating cost
$304per day
avg. revenue, all payers

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

What families pay in IL

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145571. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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