Macomb Post Acute Care Center
8 Doctors Lane, Macomb, IL 61455 · For profit - Limited Liability company · 80 certified beds · (309) 833-5555 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (34% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 2 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 18% of its spending goes to commonly-owned related companies
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) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 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 2 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 4.4% | 13.4% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.7% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 97.3% | 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 | 1.0% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 10.1% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 29.3% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 86.7% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.7% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.4% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.5% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.1% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 94.0% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.8% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 28.6% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.55 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.05 | 2.22 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
56.4% 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 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 56.4%CMS range 46.7–66.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.0–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not 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 stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 3.9–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.07 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 80 beds and averages 54.8 residents a day — about 68% occupied, or roughly 25 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.81 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.76 hrs/resident/day on weekends vs 4.23 on weekdays — 35% thinner on weekends — a notable drop. RN hours go from 1.03 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 34% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2024-10-23 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess, document and provide pain management for one resident (R2) of three residents reviewed for change in condition. This failure resulted in no pain management provided for 7 hours after R2 fell and sustained a left hip fracture Findings include: Facility Policy/Pain Management and assessment dated [DATE] documents: Evaluation and Assessment: Comprehensive pain assessment tool will be completed upon admission, transfer or onset of new pain which includes: Quality of pain (e.g. burning, aching, numbness) Pain intensity (numeric, visual analog scale, or nonverbal behavior, changes in function observation) Changes in mood state (e.g. depression, anxiety) Location and/or radiation of pain Factors that palliate or provoke pain Characteristics of pain (i. e., stable, progressive, crescendo) Facility Policy/Change in Condition Procedure dated 9/21/2022 documents: The following guidelines will be utilized as appropriate to each situation 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.
- Actual harm · Gcited before2023-12-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish appropriate fall interventions for one cognitively impaired resident (R2) and failed to prevent falls with injury for two of three residents (R1 and R2) reviewed for fall with injuries in a sample of three. These failures resulted in R1 requiring hospitalization, sustaining scalp lacerations and a cervical fracture, and subsequently resulting in R1's death, and R2 requiring hospitalization and sustaining a scalp laceration. Findings include: Facility Fall Policy, dated [DATE], documents: it is the policy of the Facility to provide guidelines for the appropriate handling of a resident's fall, accident or incident; the Facility recognizes each situation is unique and must be handled in the manner is most appropriate at the time and for the nature of the change in the condition; guidelines will be utilized as appropriate to each situation and change in condition. Facility Resident Rights Policy, dated [DATE], documents: It is the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-12 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to have adequate processes in place for acquiring /receiving refill prescriptions for narcotic medications for one (R4) of three residents reviewed for pharmaceutical services in a sample of four. Findings include:The facility's policy, Medication Orders IB2: Controlled Substance Prescriptions, dated November 2021, documents not in it's entirety, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist…
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 · F2025-04-17 · 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 ensure a multidose tuberculin vial was dated when opened. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility's Storage, Labeling of OTC (over the counter) Medication, Destruction and Disposal of Medication policy, dated/revised November 9th, 2021, documents, Purpose: To ensure that medications and biological are stored in a safe, secure storage and safe handling. Medications requiring refrigeration should be stored in the refrigerator located in the drug room at the nurse's station. Medications should be stored separately from food and must be labeled. Please refer to package insert for specific temperature requirements of medication. On 4/16/25 at 9:30 AM V3 (LPN/Licensed Practical Nurse) opened the refrigerator located in the medication room. On the top shelf of the door in the refrigerator was one vial of Aplisol (Tuberculin) units/0.1 ml (milliliter). Vial was opened, one fourth of the way full, and was not dated when opened. V3 verified the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-17 · tag F0806 — failed to honor food preferences — widespreadEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 offer food substitutions of similar nutritive value. These failures have the potential to affect all 60 residents residing within the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 4-14-25 and signed by V1/Administrator documents 60 residents currently reside within the facility. The Substitution policy dated 12/30/24, documents Food Substitutions will be made as appropriate or necessary. Policy Interpretation and Implementation 1. The food services manager, in conjunction with the clinical dietitian, may make food substitutions as appropriate or necessary. The food services shift supervisor on duty will make substitutions only when unavoidable. 2. The food services manager will maintain an exchanged list identifying the seven (7) exchanges of food groups. When in doubt about an appropriate substitution, the food services manager will consult with the dietitian prior to making…
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 before2025-04-17 · 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 complete and record cool down temperatures for meat that was prepared ahead and stored in the facility's refrigerator for future use, ensure facial hair was appropriately restrained within a hair net while in the kitchen, ensure a gallon of milk's temperature was kept below 41 degrees Fahrenheit, and ensure the sanitation buckets had the appropriate amount of quaternary ammonium. These failures have the potential to affect all 60 residents residing within the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 4-14-25 and signed by V1/Administrator documents 60 residents currently reside within the facility. The Food Temperature policy dated 12/30/24, documents Food will be stored in accordance with local, state, and federal guidelines. Policy Interpretation and Implementation 1. Food will be stored in accordance with local, state, and federal guidelines. 3. Food in refrigerators will be kept at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-17 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 a resident with a Failure to Thrive diagnosis was provided with Physician ordered double meal portions for one of four residents (R52) reviewed for Nutrition in the sample of 38 Finding include: The facility's Therapeutic Diets policy, dated 12/30/24, documents Therapeutic diets shall be prescribed by the attending physician. The facility will strive for the fewest possible dietary restrictions. The food service manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. On 4/14/25 at 11:00 AM, R52 was in his room sitting up in bed. At this time R52 stated he has a note on all of his dietary meal slips that document Double portions and Cottage cheese with all meals. R52 stated I don't get this. I asked about it because I am not sure where that note came from. The dietary staff told me that when everyone is done being served, I can ask for a second portion. So, a lot…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-10-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide treatment to a scalp laceration post fall and failed to provide post fall neurological monitoring for one resident (R1) of three residents reviewed for change of condition. Findings include: Facility Policy/Fall/Accident/Incident Protocol dated 8/1/22 documents: The following guidelines will be utilized as appropriate to each situation and change in condition: Nursing evaluation on all resident falls, witnessed and unwitnessed Complete set of vital signs (temperature, pulse, respirations, blood pressure and oxygen saturation) including pulse oximetry Neuro-checks to be initiated with every un-witnessed fall and witnessed fall with head injury Contact On-call Nurse Notify physician Notify family Document progress note (May complete in Risk Management) Complete Risk Management Obtain complete vital signs including pulse oximetry at a minimum of every shift for 72 hours Document in chart minimum of 72 hours post fall. Progress Note dated 9/27/24 at 11:17pm indicates R1was found on the floor on his bottom.…
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 before2024-06-05 · 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 ensure walk-in coolers in the kitchen maintained a temperature of less than 40 degrees Fahrenheit/F and that food in refrigerators were kept at a temperature of 41 degrees Fahrenheit or below. This failure has the potential to affect all 50 residents residing in the facility. Findings include: The facility's Policy and Procedure Refrigerators and Freezers revised 11/15/21 states, Policy Statement: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 1. Acceptable temperatures should be 35 degrees F to 40 degrees F for refrigerators and less than 0 degrees F for freezers. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. The facility's Policy and Procedure Food Temperatures revised 11/5/21 states, Policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 upon observation, interview, and record review, the facility failed to remove soiled gloves and perform hand hygiene before cleansing a wound, failed to wear gloves while touching wound dressing materials, and failed to wash hands before touching clean items after performing wound care for one of one resident (R1) reviewed for wound care in the sample of seven. Findings include: The facility's Clean Dressing Change Policy undated states, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. 9. Loosen the tape and remove the existing dressing .10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound. (i.e., clean outward from the center of the wound). Pat dry with gauze. 14. Wash hands and put on clean gloves. 15. Apply topical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and record review, the facility failed to ensure a resident had physician orders and a diagnosis for use of an indwelling urinary catheter and failed to ensure a resident's indwelling urinary catheter did not come in direct contact with the ground for one of two residents (R4) reviewed for indwelling urinary catheters in the sample of seven. Findings include: The facility's Policy and Procedure: Indwelling Catheter dated 12/29/23 documents the physician's order for indwelling urinary catheters will note the size French and bulb inflation (milliliters). R4's Hospital Records Discharge Orders document R4 discharged from the hospital on 5/23/24 after management of a femur fracture with repair. These same Hospital Records do not document an order for R4 to admit to the skilled nursing facility with an indwelling urinary catheter. R4's admission Record documents R1 admitted to the facility on [DATE]. R4's current Physician Orders do not document an order for R4's indwelling urinary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions for residents with open wounds, indwelling urinary catheters, and peripherally inserted central catheters/PICC for three of six residents (R1, R4 and R6) reviewed for Enhanced Barrier Precautions in the sample of seven. Findings include: The facility's Policy and Procedure Enhanced Barrier Precautions dated 3/27/24 states, Policy: It is the policy of this facility that Enhanced Barrier Precautions (EBP) are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. They are a strategy in nursing homes to decrease transmission of CDC (Centers for Disease Control and Prevention) targeted and epidemiologically important MDROs (Multidrug-Resistant Organisms) when contact precautions do not apply. EBP is used during high-contact care activities for residents with chronic wounds or indwelling medical device, regardless of MDRO status, in addition to residents who have an infection or colonization…
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 18 citations
- Potential for harm · Dcited before2024-02-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the Facility failed to develop a Resident centered Care Plan for three Residents (R6, R9, R17) of 33 reviewed for Care Plans in a sample of 33. Findings include: Facility Comprehensive Care Plan Policy and Procedure, revised 6/25/20, documents: an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the Resident's medical, nursing, mental and psychological needs is developed for each Resident; the Facility's Care Planning/Interdisciplinary Team (IDT), in coordination with the Resident/Family/Representative, develops and maintains a Comprehensive Care Plan for each Resident that identified the highest level of functioning for the Resident to be expected to attain; the IDT documents in the clinical record the Resident's status in triggered areas; each Resident's Comprehensive Care Plan has been designed to incorporate identified problem areas, risk factors, treatment goals, objectives, aid in preventing/reducing declines in functional status/levels and enhance optimal functioning; and Care Plans are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the Facility failed to follow physician orders for compression stockings for one of 33 Residents (R9) reviewed for quality of care in a sample of 33. Findings include: Facility Physician Orders Policy and Procedure, revised 2/14/23, documents: to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards; physician orders must be documented clearly in the medical record including the components of a complete order; clear and complete orders will be transcribed to the appropriate administration record; monthly review of physician orders will be completed to assure appropriateness, accuracy and completeness; adherence to Physician Orders will be reviewed quarterly by the Quality Assurance Committee for recommendations for sustaining professional standards; and the licensed nurse is required to record the order on the Physician Order Sheet and on the appropriate administration record and also do a progress noted. R9's Physician Order Sheet/POS, dated 2/21/24, documents R9's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a pressure ulcer on re-admission, to administer a physician ordered treatment for a pressure ulcer and provide timely incontinent care and pain management for a resident with a pressure ulcer for one of two residents (R6) reviewed for pressure ulcers in the sample of 33. Findings include: The Facility's Skin Prevention, Assessment and Treatment policy dated 5/2/22, states Purpose: To promote healing of existing pressure ulcers. Procedure: Interventions for prevention or active skin alterations may include but are not limited to: i. Keep skin clean and dry; j. Incontinence care after each incontinent episode. 3. Upon identification of the development of a wound, the wound assessments/treatment will be documented in the medical record and start the weekly Wound Log. 4. Wounds are treated based on the etiology of the wound. Factors relevant to the selection of treatments include: a. Ulcer location, size, and depth; b. Presence 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.
- Potential for harm · Dcited before2024-02-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the Facility failed to implement designated post-fall interventions for one of two Residents (R23) reviewed for Falls in a sample of 33. Findings include: Facility Fall /Accident/Incident Protocol Policy and Procedure, revised 8/1/22, documents: it is the policy of this Facility to provide guidelines for the appropriate handling of a Resident's fall; we recognize that each situation is unique and must be handled in the manner that is most appropriate at the time and for the nature of the change of condition; a nursing evaluation on all Resident falls; and complete Risk Management. Facility Comprehensive Care Plan Policy and Procedure, revised 6/25/20, documents: an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the Resident's medical and nursing needs is developed for each Resident; and each Resident's Comprehensive Care Plan has been designed to incorporate identified problem areas, risk factors, treatment goals, objectives, aid in preventing/reducing declines in functional…
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 · D2024-02-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 document the justification for duplicate antipsychotic medication therapy, ensure resident behaviors/symptoms to justify the use of antipsychotic medications, attempt a gradual dose reduction on antipsychotic medications, accurately complete psychotropic medication consents, complete psychotropic assessments prior to the use of antipsychotic medications and document the residents response to non-pharmacological interventions to manage behaviors/symptoms for two of five residents (R6, R17) reviewed for unnecessary medications in the sample of 33. Findings include: The Facility's Psychotropic Medication Management policy dated 12/4/19, states 1. An assessment must be conducted to identify specific behaviors/symptoms, potential causative factors, and recommendations for managing behaviors. 2. The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-12-23 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
Based on interview and record review the facility failed to respond to resident call lights in a timely manner and comply with resident requests for assistance, for four of four residents (R2, R3, R4, R5 and R6) reviewed for call light response in a sample of four. Findings include: Facility Resident Rights Policy, dated 11/5/19, documents: It is the policy of the facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and Residents as outlined by the State of Illinois, Illinois Department of Public Health, Centers for Medicare and Medicaid/CMS; recognizing that society is dynamic and the rights of Residents are continually evolving; and strive to improve the quality of care through a multi-disciplinary approach recognizing that each Resident is an individual with unique needs; and the Facility develops policies and procedures to assist in the support of patient's rights. Facility Assessment, dated 8/23/23, documents: Nursing Services, the Facility must have sufficient…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop a Care Plan for one (R1) of three Residents reviewed for Care Plans in a sample of three. Findings include: Facility Assessment, dated 8/23/23, documents: Nursing Services, the Facility much have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical wellbeing of each resident, as determined by resident assessments and individual plans of care. Facility Resident Rights Policy, dated 11/5/19, documents: it is the policy of the Facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlined by the State of Illinois, Illinois Department of Public Health, Centers for Medicare and Medicaid/CMS; recognizing that society is dynamic and the rights of residents are continually evolving;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-04 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to answer resident call lights timely for five (R1, R2, R3, R4 and R5) of seven Residents reviewed for call lights in a sample of seven. Findings include: Facility Resident Call Bells Policy, revised 11/5/2020, documents: it is the Policy of the Facility to ensure Residents have a functioning call bell to alert staff to their needs and that calls are responded to timely; and any staff member that hears or sees a call bell on is responsible to answer within a reasonable time frame. Facility Certified Nursing Assistant Job Description, undated, documents to answer call lights promptly. Facility Resident/Family Concern/Grievance Log, 5/16/23, documents Resident concerns (three of thirteen Residents) that call lights are taking fifteen to twenty minutes to be answered on Second and Third Shift. Facility Resident/Family Concern/Grievance Log, 6/15/23, documents Resident concerns (six of thirteen Residents) that Certified Nursing Assistants (CNA's) are taking twenty to thirty minutes to answer call lights on Second Shift. 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 · D2023-01-13 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 complete a baseline care plan for one (R91) of two residents reviewed for new admission interim care planning in the sample of 16. Findings include: The facility's Interim Care Plan Policy and Procedure, revised 11/6/2019, documents Policy Statement: It is the policy of this facility to develop an interim care plan for each resident admitted . The purpose of the interim care plan is to guide care until the comprehensive care plan is complete. Policy Interpretation and Implementation: 1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan is developed upon admission. 2. The interdisciplinary team reviews the attending physician's orders (i.e., diet, medications, treatments, etc.), and admitting assessments to develop and implement the interim plan of care. 3. The interim plan of care should be implanted within twenty-four (24) hours of admission. 4. The interim plan of care will reflect severity…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 develop a plan of care for three (R1, R28, and R33) of 16 residents reviewed for care planning in the sample of 16. Findings include: The facility's Comprehensive Care Plan Policy and Procedure, revised 6/25/2020, documents An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. R28's Face Sheet, documents R28 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Initial Smoking Evaluation was completed on 6/14/21 and was re-evaluated again on 9/14/22. On 1/11/23 at 10:56 am, R28 stated she does like to go outside and smoke sometimes. On 1/11/23 at 12:01 pm, V2 DON (Director of Nursing) stated the resident who smoke are all independent except for R28 who requires some assistance to get up and to go outside. On 1/12/23 at 9:35 am, R28 stated the staff got her up…
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 · D2023-01-13 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise a plan of care for two (R28 and R33) of 16 residents reviewed for care planning in the sample of 16. Findings include: The Facility's Comprehensive Care Plan Policy and Procedure, revised [DATE], documents Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly. The Facility's Quarterly Review Policy and Procedure for Care Plans, revised [DATE], documents Each resident's care plan shall be reviewed at least quarterly. The Care Planning/Interdisciplinary Team is responsible for maintaining care plans on a current status. The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans. 1. The current Care Plan for R28 documents a Focus area for R28 initiated on [DATE] as Right elbow with blanchable redness and on [DATE] a Focus area was initiated as Denuded tissue on right and left buttocks related to shearing, thin skin, sliding up…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-13 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure staff wash hands after removing soiled gloves and before placing clean gloves while performing pressure ulcer wound care and failed to document weekly skin assessments per facility policy for one of two residents (R33) reviewed for pressure ulcers in the sample of 16. Findings include: The facility's Clean Dressing Change Policy, revised, 12/5/22, states, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. 7. Wash hands and put on clean gloves. 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-13 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to change a resident's indwelling urinary catheter bag as ordered by the physician, failed to perform hand hygiene and wear gloves during indwelling urinary catheter care and failed to flush an indwelling urinary catheter as ordered by the physician for one of one resident (R33) reviewed for urinary catheters in the sample of 16. Findings include: The facility's Catheter Flush Policy and Procedure, revised 1/13/22, states, It is the policy of this facility and to ensure catheter irrigation is performed with comfort for the resident. Procedure Interpretation and Implementation: Irrigation of the catheter will provide comfort for the resident and allows the bladder to drain. 1. Verify Physician Order. 13. Remove gloves and wash hands. The facility's Catheter Care Policy and Procedure, revised 1/13/22, states, Staff will maintain consistent and adequate hygiene standards for residents with an indwelling catheter in order to maintain comfort, function, and prevent infection and other complications. Procedures: 1.…
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 · D2023-01-13 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to perform hand hygiene and maintain glove use during Gastrostomy Tube Care and failed to cleanse a Gastrostomy Tube as ordered by the physician for one of one resident (R33) reviewed for Gastrostomy tubes in the sample of 16. Findings include: The facility's Feeding Tube Dressing Change Policy and Procedure, revised 1/13/22, states, It is the policy of this facility to provide Gastrostomy and Jejunostomy site care to decrease the risk of infection. 3. Wash hands and put on clean gloves. 4. Using gauze pads and ordered cleanser, gently clean the area immediately surrounding the tube and continue working outward in a circular fashion. Be sure to clean under the bolster. 6. Pat dry after cleaning. 7. Place a dressing around the site as ordered. 10. Remove gloves and wash hands. The facility's Standard Precautions Policy, revised 1/6/21, states, Policy: It is the facility's policy that standard precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection…
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 · D2023-01-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure oxygen tubing and humidifier bottle were dated when initiated and the humidifier bottle contained distilled water for one (R91) of three residents reviewed for respiratory services in the sample of 16. Findings include: The facility's Oxygen Administration and Storage Policy and Procedure, revised 3/8/2022, documents: Purpose: To ensure staff follow safety guidelines and regulation for storage and use of oxygen. Procedure: 1. Verify provider's order for the procedure. 2. In cases of emergency, oxygen may be administered as a nursing intervention until a physician order may be obtained . 12. Label the tubing connected to the oxygen cylinder with time and date . 15. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through . General Guidelines: 7. The humidifier bottle is to be labeled with the date of application and changed weekly if refillable. Emergency Oxygen Administration: It is the Nurse's responsibility to provide…
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 · D2023-01-13 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to serve a physician ordered diet to one (R28) of two residents reviewed for nutrition in the sample of 16. Findings include: The Face Sheet for R28, documents R28 was admitted to the facility with the following diagnoses: Type 2 Diabetes Mellitus, Atypical Facial Pain, Temporomandibular Joint Disorder, Articular Disc Disorder of Temporomandibular Joint, Dysphagia and Other Symptoms and Signs Concerning Food and Fluid Intake. The Order Summary Report for R28, dated 1/12/23, documents a Physician Order was obtained on 11/29/21 for R28 as Regular Diet, Mech Soft: Chopped/Advanced/Soft and Bite Sized Texture, Regular/Thin consistency, ice cream with lunch and supper. The Breakfast meal ticket for R28, dated 1/12/23, documents R28 breakfast menu including Ground Sausage w(with)/gravy. On 1/12/22 at 9:35 am, R28 was in her room eating breakfast. R28 had a plate with scrambled eggs and a whole sausage patty and no gravy. On 1/12/22 at 9:38 am, R28 stated she cannot chew the sausage because it is too tough and is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to wash hands after removing gloves during incontinence care for one of one resident (R33) reviewed for bowel and bladder in the sample of 16. Findings include: The facility's Standard Precautions Policy, revised 1/6/21, states, Policy: It is the facility's policy that standard precautions will apply to the care of all residents in all situations regardless of their suspected or confirmed infection disease process. Standard Precautions assume all blood, body fluids and secretions/excretions, non-intact skin and mucous membranes may contain transmissible infectious agents. Procedure: Handwashing 1. After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; 2. Immediately after gloves are removed, between resident contacts and when otherwise indicated to avoid transfer of microorganisms to other residents or environments; and 3. Between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Gloves Use: 1. Staff will…
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 · C2024-02-23 · tag F0847 — widespreadInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to explain the arbitration agreement to the resident, or their representative in a form or manner they could understand. This had the potential to affect all 49 residents residing in the facility. Findings include: The Binding Arbitration Agreement documents This Arbitration Agreement is entered into by and between the Resident the Resident Representative in his/her individual and representative capacity and (the Facility) (the Resident, Resident Representative, and Facility are referred to herein collectively as the Parties) in connection with that certain admission agreement (the admission Agreement), executed by the Parties simultaneously herewith. The Parties believe that it is in their mutual interest to provide for a less burdensome and more efficient and cost-effective manner for handling their respective disputes. Accordingly, the Parties agree as follows: 8. The Arbitration Agreement was explained to the Resident, his/her Resident Representative, or Guardian with legal authority to enter into the Arbitration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to STERN CONSULTANTS — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 3 of 5 | 2.2 | +0.8 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 21 homes this chain runs (chain average 2.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| NEWHOUSE, ERIC | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 06/01/2021 |
| ERBLICH, AVRAHAM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2021 |
| FRIEDMAN, BENJAMIN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2021 |
| MATHEW, STANLEY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| MILLMAN, CHAIM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2021 |
| SHEPS, BORUCH | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2021 |
| ETN FAMILY HOLDINGS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2021 |
| STERN THERAPY CONSULTANTS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/25/2025 |
| COOK, WINDY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2021 |
| MAYHUGH, KIMBERLY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/20/2022 |
| PLEW, ANDREA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2021 |
| NEWHOUSE, TEMI | Individual | TRUSTEE OF THE SNF | since 06/01/2021 |
| E NEWHOUSE FAMILY TRUST | Organization | ADP OF THE SNF | since 06/01/2021 |
| MACOMB REALTY LLC | Organization | ADP OF THE SNF | since 06/01/2021 |
| T NEWHOUSE FAMILY TRUST | Organization | ADP OF THE SNF | since 06/01/2021 |
CMS files one row per role, so the 32 rows in the source record cover these 15 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.
5 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.
About 70% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $901K paid to related parties — landlords or management companies under common ownership — equal to about 18% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145021. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-17, 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.