Avenues At Litchfield
1024 East Tyler, Litchfield, IL 62056 · For profit - Corporation · 65 certified beds · (217) 324-3842 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (12% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (15) — 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)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.9% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.2% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.4% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 93.6% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.0% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 2.8% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 44.6% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.8% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 9.0% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 49.3% | 21.7% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.70 | 2.02 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 3.33 | 2.22 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
Staffing
How full it usually is: this home is certified for 65 beds and averages 63.1 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 1.67 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.20 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.91 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 1.47 hrs/resident/day on weekends vs 1.75 on weekdays — 16% thinner on weekends. RN hours go from 0.23 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 12% 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.
15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.
- Potential for harm · D2026-05-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 interview and record review the facility failed to prevent resident to resident abuse for 2 (R3, R4) residents reviewed for abuse in the sample of 3. Findings include: R3's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including schizophrenia and anxiety. R3's Quarterly Minimum Data Set (MDS) dated , 1/14/2026 documents R3 is cognitively intact and physical behavioral symptoms not directed towards others occurred daily. R3's Nursing Note, dated 2/12/2026 at 5:13 PM documents reported to me by V6, Activity Director that R4's roommate was yelling and cussing, he then slapped R3 in the face, when I went to room R3 was laying on his bed quietly and his roommate (R4) was still angry. (R4) was sent to the ER (Emergency Room) for eval (evaluation.)On 5/19/2026 at 1:40 PM R3 stated a few months ago his roommate (R4) slapped him across the face out of the blue and he was upset about it because he didn't know why he slapped him. R3 stated they are no longer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-20 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 the facility policy and prevent resident to resident abuse for 2 (R3, R4) residents reviewed for abuse in the sample of 3.Findings include: R3's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including schizophrenia and anxiety. R3's Quarterly Minimum Data Set (MDS) dated , 1/14/2026 documents R3 is cognitively intact and physical behavioral symptoms not directed towards others occurred daily. R3's Nursing Note, dated 2/12/2026 at 5:13 PM documents reported to me by V6, Activity Director that R4's roommate was yelling and cussing, he then slapped R3 in the face, when I went to room R3 was laying on his bed quietly and his roommate (R4) was still angry. (R4) was sent to the ER (Emergency Room) for eval (evaluation.)On 5/19/2026 at 1:40 PM R3 stated a few months ago his roommate (R4) slapped him across the face out of the blue and he was upset about it because he didn't know why he slapped him. R3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-10-03 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 Registered Nurse (RN) was working at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 62 residents living in the facility. Findings includes: The facility's partial August 2024 Daily assignment sheets for 8/30/2024 and 8/31/2024, documented that there was not consecutive 8 hours of consecutive RN coverage. The facility's September 2024's RN staffing documented that there was not consecutive 8 hours of consecutive RN coverage on 9/9/24, 9/10/24, 9/11/24, 9/13/24, 9/14/24, 9/15/24, 9/17/24, 9/18/24, 9/19/24, 9/23/24, 9/24/24, 9/25/24, 9/27/24, 9/28/24, 9/29/24. On 09/30/2024 at 4:00PM, V2, Director of Nurses, stated that she was told by her corporate nurse that as long as it was a consecutive 8 hours then her night RN would count as the RN. V2 stated that that RN works 10 pm to 6 am and that the new day starts at 12:00 AM. V2 continued to state that she guessed then the new day would start at 12 am and that only 6 of the 8 hours would be on the new day. On 10/02/204 at 3:10 pm,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-03 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure 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
Based on observation, interview and record review, the facility failed to ensure food was at the proper holding temperature at the steam table for 4 of 12 residents (R8, R21, R23, R35) reviewed for food temperatures in the sample of 62. Findings include: On 10/1/2024 at 11:55 PM, during the lunch service R8 was served mechanical hot dog meat and tater tots. On 10/1/2024 at 11:56 PM, R35's meal ticket documented a mechanical diet. On 10/1/2024 at 11:58 AM, during the lunch service R35 was served a mechanical hot dog meat on a bun. On 10/1/2024 at 11:59 AM, during the lunch service R21 was served a mechanical hot dog meat on a bun and tater tots. On 10/1/2024 at 12:00 PM, R21's dietary ticket documents he was on a mechanical diet. On 10/1/2024 at 12:03 PM, during the lunch service R23 was served a mechanical hot dog meat on a bun and tater tots. On 10/1/2024 at 12:04 PM, R23's dietary ticket documents he was on a mechanical diet. On 10/01/2024 at 12:12 AM, after the last lunch plate had been served, food temperatures were taken on the steam table with a calibrated metal thermometer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-03 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 residents were receiving the lowest effective doses, recommended by licensed pharmacists, in a timely fashion for 2 of 5 residents (R14, R38) reviewed for unnecessary medications, in the sample of 62. Findings include: 1. On 9/30/2024 at 9:30 AM, R14 stated, They give me a shot of something in the morning. R14's Face sheet dated 10/3/2024 documents, Long term (current) use of insulin. Consultant Pharmacist Recommendation to Nursing dated 8/23/2024 documents, Medication reduction request- Resident is on the following diabetic medications: Metformin ER (Extended Release) 500 mg (Milligrams) 1 tablet in the morning and 2 tablets at bedtime, Basaglar 40 units once daily, and Fiasp 10 units with meals. Recent blood glucose monitoring low. 8/23/2024 54 (normal 70-100). Most recent A1C (Hemoglobin A1C levels indicate the percentage of hemoglobin coated with glucose) 6-2024 (June 20224) 4.5 (Normal: Less than 5.7%). Recommend further reduction of basaglar to 35 units once daily. R14's Physicians Orders dated 10/3/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-19 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 Registered Nurse (RN) was working at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 62 residents living in the facility. Findings include: On 09/17/2023 at 9:55 AM, V1, Administrator stated we are not having any issues with RN coverage. We have a RN working every day. On 9/17/2023 at 10:15 AM, V4, Licensed Practical Nurse (LPN) stated We did not have a RN working on Saturday because she had a wedding to go to. We were without a RN that night. Staffing schedules were reviewed from 8/25/2023 to 9/17/2023 and no RN was documented as working on Saturday, 9/16/2023. On 9/17/2023 at 9:57 AM, V1 stated We did have a RN call off on 9/16/2023 and we did not have a RN working that day. I realize the regulations require a RN to work 8 consecutive hours, seven days a week. On 9/17/2023 at 10:30 AM, V2, Director of Nursing stated, The RN called off on 9/16/2023 but normally we have a RN working every day for 8…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-19 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to obtain lab draws as ordered by the physician for monitoring therapeutic drug levels for 1 of 7 residents (R11) reviewed for unnecessary medications in the sample of 64. Findings include: R11's Face Sheet documents her diagnoses to include Post Traumatic Seizures and Personal History of Traumatic Brain Injury. R11's Physician Order Summary dated 9/19/23 documents the following orders: 8/31/23: Trileptal Oral Tablet 300 milligrams (mg) (Oxcarbazepine) Give 1 tablet by mouth in the evening related to Post Traumatic Seizures. Give with 150 mg tab to equal 450 mg daily. 8/31/23: Levetiracetam Oral Tablet 1000 mg (Levetiracetam) Give 1 tablet by mouth two times a day related to Post Traumatic Seizures; Personal History of Traumatic Brain Injury. 12/13/22: CBC (Complete Blood Count), B12, CMP (Complete Metabolic Profile), TSH (Thyroid Stimulating Hormone Level), VITAMIN D LEVEL, HGBA1C (Hemoglobin A1C), Trileptal and Keppra (Levetiracetam) level every 6 months-April/October. R11's Electronic Medical Record documents, under lab…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-07-21 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 64 residents in the facility. Findings include: On 7/20/22 at 11:30 AM, the Nursing Working staffing schedule from January 1, 2022, through July 19, 2022 was reviewed with V2, Director of Nurses. The facility did not have consecutive 8-hour RN coverage for the following days: 1/19/22, 3/24/22, 3/28/22, 3/29/22, 4/1/22 through 4/18/22, 4/21/22, 4/25/22, 4/29/22, 4/30/22, 5/8/22, 5/27/22, 6/6/22, 6/10/22, 6/18/22, and 6/19/22. On 7/20/22 at 11:00 am V2, Director of Nurses (DON), stated she knows there were some issues with RN coverage as one RN left and came back. V2 stated she has only been employed at the facility for four months. V2 stated she has hired two RNs for evenings since she started. 7/21/22 at 9:45 AM V2 stated that they do not have a policy on staffing. V2 stated that they use the CMS guidelines. The Resident's Census and Conditions of Resident, CMS 672, dated 7/18/2022, documents that the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-21 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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 properly label and store medication. This failure has the potential to affect all 64 residents living in the facility. Findings include: On 7/19/2022 at 8:14 AM the facility's medication room was inspected. The medication room contained the following medication: c1. A clear unlabeled bag of 53 dark pink pills. The clear bag had These are 50mg Benadryl not 25mg handwritten in red ink on the clear bag. On 7/19/2022 at 8:17 AM, V4, Licensed Practical Nurse (LPN), stated that she did not know what was in the bag. V4 stated that It's illegal and they (pills) are not supposed to be in there (bag). V4 stated that the medication was stock and used for everyone unless they have an allergy. On 7/19/2022 at 8:19 AM V5, LPN, stated that, The only thing we can do is fix our mistakes. 2. R19's open, unlabeled with open date, vial of Lantus 100 units. On 7/19/2022 at 8:25 AM, V2, Director of Nursing (DON), stated that Lantus is good for 28 days once open. V4 stated that this is why there is an open date. V2 stated that when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-21 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the Facility failed to document and receive prior approval from the dietician before utilizing substitutions. This failure has the potential to affect all 64 residents residing in the facility. Findings include: On 7/18/2022 at 11:00 AM, V9, Dietary Aid, was observed serving Pork Loin, Stuffing, Brussel Sprouts and Applesauce with cinnamon for lunch. The Facility's Diet Spreadsheet, Spring/Summer 2022 Week 4 documents that Pork Loin, Zucchini Cornbread Dressing Bake, Brussels Sprouts, and Banana Split Cake were on the menu to be served. On 7/19/2022 at 1:30 PM, V6, Kitchen Manager stated, We didn't have Zucchini, just stuffing and our Bananas were liquified, so I sent them back. On 7/20/2022, at 2:46 PM, V1, Administrator stated, If I had known they didn't have zucchini or bananas I would have gone to the store. We just talked about following the menu. I would expect them to follow it. At this time, V1 confirmed the menu listed above was for 7/18/2022 and the menu was not followed. On 7/21/2022 at 11:45 AM, V1 stated, She (V6)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · F2022-07-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the Facility failed to maintain a sanitary environment in the food storage, prep, and serving area. This failure has the potential to affect all 64 residents residing in the building. Findings include: On 7/18/2022, at 8:45 AM, the white air conditioning unit in the dry food storage area had a black substance covering the vent. V6, Kitchen Manager, stated, I don't know what that is. I will have the maintenance man clean it. On 7/18/2022 at 10:35 AM V9, Dietary Aid, was preparing the mechanical soft meat. This surveyor saw a blackish/brown bug, approximately one inch in length, with long antennas scurry across the floor in the kitchen near the steam table. V9, nonchalantly stated, Yeah, that's a roach. I see them off and on. Usually, they are dead because they spray for them. On 7/18/2022, at 10:45 AM, V6, stated, We are supposed to call the pest control company if we see them. On 7/19/2022 at 8:30 AM, V1, Administrator stated, The black stuff was a foam seal that was in there to keep the air conditioner from rattling. It had gotten…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-07-21 · tag F0912 — widespreadProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and record review, the facility failed to provide 80 square feet of floor space per resident bed for 33 two-bed resident rooms for 60 of 62 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31,R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R45, R46, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61, R62 and R63 ) reviewed for room sizes in the sample of 63. Findings include: 1. The facility has 33 two-bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide 76 square feet per bed. All these rooms are certified for Medicaid beds. 2. R1, R8, R12, R14, R15, R17, R18, R20, R23, R26, R27, R30, R32, R34, R36, R37, R39, R40, R41, R42, R44, R45, R46, R47, R49, R52, R55, R58, R59, R61, and R63 reside in rooms XX-XYZ on the A-hall. 3. R2, R3, R4, R5, R6, R7, R9, R10, R11, R13, R16, R19, R21, R22, R24, R25, R28, R29, R31, R33, R35, R38, R43, R48, R50, R51, R53, R54, R56,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-07-21 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide effective pest control program so that the facility is free of pests. 1. On 7/18/22 at 10:30 AM R38 stated that she has had to kill multiple bugs in her room. R38 stated that she has squashed spiders and roaches in her room. 2. On 7/19/2022 from 1:30 PM to 2:00 PM multiple large blackish brown bugs approximately 1 inch in length with antennas was observed crawling on the floor. On 7/19/22 at 2:00 PM V2, Director of Nursing (DON) identified the bug as a roach. 3. On 7/21/2022 at 11:50 AM observed a large black bug running across the floor in the social service office. On 7/21/22 at 3:00 PM V10, Maintenance, stated that they do have an exterminator company that comes out monthly. V10 stated that the company was out last month but they only spray the entry points. When asked to clarify? V10 stated that the company only sprays the entrances to the building and other areas when identified. 4. On 7/18/2022 at 10:35 AM V9, Dietary Aid, was preparing food in the prep area. This surveyor saw a blackish/brown…
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.
- No harm found · Bcited before2024-10-03 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interview the facility failed to provide 80 square feet of floor space per resident bed for 58 of 62 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, R16, R17, R18, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R41, R42, R43, R44, R45, R46, R47, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61 and R62) reviewed for room size requirements in the sample of 62. Findings include: On 10/01/2024 at 3:19 PM, V1, Administrator, stated there have not been any changes to any of the rooms since the last survey and she has a waiver for these rooms because they are less than 80 square feet. The facility has 33 two bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide 76 square feet per bed. All rooms are certified for Medicaid. On 10/1/2024 at 2:42 PM, R1, R3, R4, R6, R7, R9, R10 R11, R15, R17, R22, R27, R34, R36, R37, R39, R41, R43, R44, R46, R48, R49, R50, R51, R53, R56, R58 and R59 all reside on 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.
- No harm found · Ccited before2023-09-19 · tag F0912 — widespreadProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, and interview the facility failed to provide 80 square feet of floor space per resident bed for 62 of 64 residents ( R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R43, R44, R45, R46, R47, R48, R49, R50, R51,R52, R53, R54, R55, R56, R57, R58, F59, R60, R61, and R62) reviewed for room size requirements in the sample of 64. Findings include: On 9/17/2023 at 9:02 AM, V1, Administrator, stated there have not been any changes to any of the rooms since the last survey and she has a waiver for these rooms because they are less than 80 square feet. The facility has 33 two bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide 76 square feet per bed. All of these rooms are certified for Medicaid. On 9/17/2023 at 2:02 PM, V8, Maintenance Man, measured the rooms and verified that (R2, R4, R6, R9, R15, R17, R18, R19, R20, R22, R24, R26, R28, R29, R30, R32, R33,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in IL
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 14E264. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-10-03, 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.