Generations at Applewood

Location & what’s nearby

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

Quality measures — how residents actually fare

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

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

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

63.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 23.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 60 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 38% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 154 beds and averages 128.9 residents a day — about 84% occupied, or roughly 25 beds typically open. It usually has some room. 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 3.31 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.96 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.92 hrs/resident/day on weekends vs 3.47 on weekdays — 16% thinner on weekends. RN hours go from 1.03 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 56% is about the same as the national median of 45%. 1 administrator has left in the past year.

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.

66 citations, most serious first. The 29 most serious are shown; the remaining 37 are one tap away and print in full.

• Immediate jeopardy · J2023-12-19 · tag F0678 — failed to provide CPR when needed — isolated
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their change in condition policy, and to provide emergency life sustaining measures for one (R8) of five residents reviewed for change in condition and emergency life sustaining measures in a sample of 17. This failure resulted in an Immediate Jeopardy when R8 was found to be unresponsive and did not receive life sustaining measures due to the resident being in the wrong bed and not identified as a full code. The Immediate Jeopardy began on [DATE] when R8 was found to be unresponsive and did not receive life sustaining measures due to the resident being in the wrong bed and not identified as a full code. V1 (Administrator) was notified on [DATE] at 11:46 am. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but the non-compliance remains at level Two because time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: Resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited beforedisputed · IDR2026-07-02 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Failures at this level required more than one deficient practice statement.A. Based on interview and record review, the facility failed to assess and document resident vital signs for a resident experiencing a change in condition and failed to ensure a resident received timely emergency treatment for one resident reviewed on the sample list of 33. These failures resulted in R7's delay in transferring to a higher level of care to receive emergency care after R7's change in condition.B. Based on observation, interview and record review, the facility failed to implement skin prevention interventions and failed to identify skin integrity impairments for two residents reviewed for skin integrity. These failures affect two residents (R32, R89) reviewed for skin integrity on the sample list of 33.C. Based on observation, interview and record review, the facility failed to ensure medications administered are documented at the time of administration. The facility also failed to ensure that medications were administered…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
• Actual harm · Gcited beforedisputed · IDR2026-07-02 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observations, interviews, and record review the facility failed to implement preventive interventions to maintain skin integrity, failed to ensure that the LALM (Low Air Loss Mattress) as on the correct settings while in use, failed to ensure that multiple linen layers were not beneath the resident while on a LALM, failed to timely identify skin integrity impairments, failed to follow physician orders, and/or failed to document/administer prescribed treatments for 10 of 33 residents (R8, R11, R12, R47, R52, R55, R90, R100, R118, R121, R123) in the sample reviewed for pressure ulcers. These failures resulted in R118 developing a (facility acquired) infected (stage 4) sacral wound on or about 5/5/26 which required hospitalization, antibiotic medication, and surgical debridement. Findings include: R118 was admitted to the facility on [DATE]. R118's diagnoses include type II diabetes mellitus, generalized weakness, and (4/14/26) sacral pressure ulcer - stage 4. R118's (4/10/26) functional assessment…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has no plan of correction
• Actual harm · Gcited before2026-07-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify R2's attending physician of a scheduled extensive dental extraction procedure. The facility also failed to communicate with the cardiologist and/or attending physician of R2's use of multiple blood thinning medications and request orders related to these medications in relation to R2's scheduled extensive dental extraction procedure. These failures affect one resident (R2) of three residents reviewed for quality of care. These failures caused R2 to experience uncontrolled hemorrhaging from R2's gums/oral cavity after having extensive extraction of ten teeth. R2 required emergent transfer to the local hospital. R2 was admitted from the emergency room to the hospital with a diagnosis of Oral Hemorrhage requiring transfusion of multiple blood products.Findings include:R2's Hospital Record dated 6/1/2026, reads in part: R2 presents to Emergency Department by EMS (Emergency Medical Services) from nursing facility with a chief concern of oral…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Actual harm · Gcited before2026-05-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow their fall policy by failing to implement effective fall interventions, failed to thoroughly investigate each fall to determine root cause analysis, failed to conduct fall risk assessments after two falls and failed to conduct neurological checks for one resident (R3) out of three reviewed for falls. These failures resulted in R3 sustaining four unwitnessed falls and being diagnosed with a right femur fracture.Findings include:R3 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, type II diabetes, heart failure, osteoarthritis of knee unspecified, repeated falls, abnormalities of gait, malignant neoplasm of bronchus or lung and weakness.R3's fall risk evaluation dated 1/26/26 documents: R3 at high risk for falls due to score of 13. A score of 10 or greater, the resident should be considered at high risk for falls.R3 progress note dated 2/23/26 documents: Pain & Vitals: Resident complaints of pain in…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Actual harm · G2026-05-08 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their pain policy and provide effective pain management for one resident experiencing severe right knee pain after a fourth unwitnessed fall. These failures affect one of three residents (R3) reviewed for pain management. These failures resulted in the resident experiencing severe pain, revoking hospice services and being transferred to the hospital with a diagnosis of right femur fracture.Findings include:R3 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, type II diabetes, heart failure, osteoarthritis of knee unspecified, repeated falls, abnormalities of gait, malignant neoplasm of bronchus or lung and weakness.R3 progress notes dated 3/28/26 at 9:48PM documents: Unwitnessed fall in resident's room; heard moaning. Resident observed lying supine on floormat adjacent to bed in hospital gown, no footwear; continued to roll around on floor. Returned resident to bed and performed full body…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Actual harm · Gcited before2026-01-23 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent facility acquired pressure ulcer injury to residents at risk for pressure ulcers. The facility also failed to initiate wound treatment for facility acquired pressure ulcer. These failures affect two residents (R2, R5) of three residents reviewed for pressure ulcer/skin alteration. These failures resulted in R2 developing a facility acquired pressure ulcer injury and R5 developing three facility acquired pressure ulcer injuries.Findings include:1. R2 is a [AGE] year-old female resident. admitted in the facility on 11/27/25 and discharged on 12/12/25. admitted with multiple wounds including surgical site and pressure ulcer injuries.Record reviewed and R2 was assessed to be moderate risk for pressure ulcer. Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated11/27/25, score of 13 (Moderate Risk).On 12/05/25, it is documented that R2 had developed a facility acquired pressure ulcer injury. Location: Rear Left Thigh, with measurements of…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-01-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was properly secured while being transported using the facility's private transport vehicle. This failure affects one of three residents (R3) reviewed for falls. R3 fell forward inside the facility's private trasnport vehicle and sustained a right intertrochanteric femur fracture requiring surgical repair of Intramedullary nailing of the right proximal femur.Findings include:R3 admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis and muscle wasting and atrophy.The Facility Reported Incident dated 11/11/25 reads in part: R3 experienced a fall from wheelchair during transport while in route back to the facility after an appointment. Upon returning to facility, R3 was assessed and complained of severe pain in right leg. Nurse practitioner present in the facility and ordered to send R3 out to emergency department via 911 (emergency transfer). R3 was transferred to local hospital. Hospital records indicate 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-07-08 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to identify causes of resident weight loss; failed to identify that a resident had AIDS (acquired immunodeficiency syndrome); failed to monitor R3's HIV diagnosis according to professional standards; failed to develop a plan of care to address known weight loss and refusals of care; failed to notify providers of abnormal lab results; failed to notify providers of severe weight loss; failed to follow physician orders for lab work; failed to notify the provider/implement dietician recommendations timely. These failures affect 1 resident (R3) reviewed for quality of care. These failures caused harm to R3 as evidenced by a 5.5% weight loss in 6 days, an 8.2% weight loss within a month and a 16% weight loss within 3 months.Findings include:R3's face sheet documents in part a diagnosis of HIV (Human Immunodeficiency Virus) hemiplegia and hemiparesis of the right side, memory deficit following unspecified cerebrovascular disease, and schizoaffective…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-05-29 · tag F0711 — isolated
  Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
  What the surveyor found here — the official record, unedited, may be distressing

  Deficiency Text Not Available

  Nursing and Physician Services Deficiencies · Deficient, Provider has plan of correction
• Actual harm · Gcited before2025-05-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation and record review, the facility failed to develop and implement pressure ulcer prevention intervenctions for three of 12 residents (R49, R24, R120) reviewed for pressure ulcers. Findings include: 1. On 05/07/25 at 9:53 AM V4, LPN, said R49 has pressure wounds on her sacrum and legs. R49 said I can't move my legs, they stay like this. R49's legs contracted and knees touching with dressing on left and right knee. Pillow between legs, but knees still touching. On 5/8/25 at 1:41PM V2, Director of Nursing (DON) and V9, Wound Nurse, were interviewed together. R49 has a stage 4 pressure ulcer to her left knee that developed in house on 4/3/25. V9 stated all of R49's skin impairment locations. V2 said R49 is at high risk for skin breakdown they put a pillow between her knees and use wedges for positioning. Repositioning is done every 2 hours, we do that for everyone. V9 said R49 is not able to reposition herself. The surveyor asked for documentation of the skin prevention interventions used to prevent pressure on R49's knees. V2 said I will check 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Actual harm · Gcited before2025-01-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent development of a pressure ulcer; failed to promote wound healing and prevent infection for a dependent resident who was assessed as being at risk for pressure ulcer; and failed to perform weekly skin assessments as ordered. These failures applied to one (R1) of three residents reviewed for pressure ulcers and resulted in R1 developing a stage 4 facility acquired pressure ulcer to her sacrum, which required hospitalization for treatment of infection and surgical wound debridement. Findings include: R1 is a [AGE] year-old female who was admitted to the facility on [DATE]. Her past medical history includes, but not limited to Local infection of the skin and subcutaneous tissue, dysphagia, peripheral vascular disease, pressure ulcer of sacral region stage 3, pressure ulcer of right elbow stage 4, venous insufficiency, hypothyroidism, hyperlipidemia, gastro esophageal reflux disease without…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-12-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to perform a safe transfer by not using the mechanical lift for 1 resident (R2) dependent on staff for transfers. This failure affected one of three residents reviewed for injury. This failure resulted in R2 sustaining an acute mildly displaced fracture of the distal femoral diaphysis on the left leg. This past non-compliance occurred from 11/7/24 to 12/4/24. The findings include: The facility reported to IDPH (Illinois Department of Public Health) that on 11/7/24 while R2 was being transferred to dialysis chair by CNA (Certified Nurses Assistant), R2 slid down and had an assisted fall. Shortly after, R2 complained of pain to left knee. Small bump noted to left knee. R2 sent to the hospital for evaluation. Imaging received from the hospital identified distal femur fracture. R2's diagnosis include but are not limited to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 5 Chronic Kidney Disease, Atherosclerosis of Native Arteries of…

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

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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement and ensure effective interventions were in place to reduce the risk of falls/falls with injury for three of three residents (R58, R69 and R80) in the sample of 22 reviewed for fall prevention program. This failure resulted in R80 being sent to the local hospital sustaining a left femoral fracture. Findings include: On 6/26/2024 at 9:40am R80 was observed in bed with one floor mat on the right side of the bed only. On 6/26/2024 9:45am V13 (Licensed Practical Nurse-LPN) observed with surveyor R80 with one floor mat and said R80 is a high fall risk and should have two floor mats, one each side of the bed. On 6/26/2024 at 10:10am V2 (Director of Nursing-DON) said R80 is a high fall risk and should always have bilateral floor mats down while in bed. A face sheet indicated R80 was admitted to the facility on [DATE] and has a diagnosis of repeated falls, syncope and collapse. An initial fall risk assessment dated , 3/12/2024 had a score…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-05-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that coffee was served at a safe temperature below 140-degrees Fahrenheit (F), failed to ensure a resident was positioned safely while providing direct resident care, and failed to develop fall prevention interventions to include monitoring for a resident with a history of falls, severe cognitive deficits, dementia, and restless agitation. This failure affected 3 of 3 residents (R1, R3, R2) and resulted in R1 spilling coffee sustaining full thickness burns to the right posterior thigh measuring 13.9x6.3x0.1cm (centimeters) and to the left thigh measuring 4.8x18.5x0.1cm. This failure also resulted in R3 rolling out of the bed sustaining a laceration to left eyebrow, subarachnoid hemorrhage, and a nondisplaced patella (knee) fracture. Findings include: 1) R's latest admit date to the facility is 4/18/24 with a diagnosis of multiple sclerosis. Alzheimer's disease with late onset, major depressive disorder and anxiety. R1's Minimum Data…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-05-30 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to provide feeding assistance for residents with visual deficits that were identified as needing assistance which resulted in an unplanned serve weight loss. This affected two of three residents (R8, R9) reviewed for unplanned weight loss. This failure resulted in R8 having a weight loss of 8.99% in one month and R9 having a weight loss of 10.6% in four months. Findings Include: 1) R8 has a diagnosis with Dementia. On 05/24/24 at 12:21PM and 12:33PM, R8 was observed with her head tilted to the ceiling with a non-focusing blank stare while eating in the dining room with no feeding assistance. R8 was observed scooping pureed food off her plate onto the tray, putting the spoon in her mouth with no food on it. R8 dropped the spoon on the tray. R8 was observed tapping around on the tray with her hand, putting her fingers in food then licking food off her fingers for twelve minutes until she touched the spoon and preceded to feed self with small amounts of food. On 05/24/24 at 12:51PM, V3 (Assistant Director of Nurses)…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-04-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and observations the facility failed to supervise an impulsive, confused resident, with unsteady gait from getting into bed with another resident. This affected two of three (R1, R2) residents reviewed for supervison/monitoring. This failure resulted in R1 screaming, crying, and feeling nervous after R2 climbed into her bed. A reasonable person would have been scared and terrified. Findings include: R1's diagnosis includes but is not limited to Dementia, Anxiety, Adjustment Disorder with Mixed Anxiety, Weakness, History of Transient Ischemic Attack, and Osteoporosis. R2's diagnosis includes but is not limited to Diabetes mellitus, Heart Failure, Vascular Dementia, and Major Depressive Disorder. Progress notes dated 12/10/23 at 5:25AM state R1 was heard yelling for help and upon entering the room staff observed her roommate (R2) in her bed. Resident (R1) was observed gripping a butter knife but was not aiming it towards R2. R1 unsure why R2 was in her bed. On 4/6/24 at 12:16PM V3, Certified Nursing Assistant (CNA), said when she walked past the room she saw one…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-12-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that oxygen was administered to a resident with labored breathing and failed to notify the physician of the change in condition for one of five residents (R8) reviewed for accommodation of needs in a total sample of 17. This failure resulted in R8 becoming unresponsive and apneic with a faint carotid pulse and expiring in the facility. Findings include: On [DATE] at 3:15 PM, V8 (Registered Nurse) said that when she was doing her rounds between 5:30 AM and 6:00 AM she noticed that R8 was having labored breathing. V8 said that R8 was in bed #2. V8 left the room and went to the computer to check R8's code status. V8 said that the resident in bed #2 was listed as Do Not Resuscitate (DNR) which was supposed to be R9, but it was not R9 in bed #2, it was R8 in the bed. V8 said that originally, she called 911 because R8 was still breathing. V8 told the paramedics that R8 is a DNR upon the paramedics' arrival and the paramedics told V8 that they will work…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to ensure effective interventions were in place to reduce the risk of falls for 1 of 3 residents (R13) reviewed for safety, this deficiency resulted in R13 falling out of bed on 11/26/2023 and being sent to the local emergency hospital, sustaining an acute intraparenchymal hemorrhage. Findings include: On 12/8/2023 at 2:31pm V22 (Certified Nursing Assistant-CNA) said on 11/26/2023 between 4:00pm and 4:30pm she rounded and observed R13's head on the metal bar underneath the bedside table on the floor. V22 said that it looked like R13 hit her head on the metal bars of the wheels of the bedside table. V22 said that R13 did not have any floor mats at the bedside, and she is a high risk for falls. On 12/13/2023 at 3:45pm, V21(Registered Nurse-RN) said on 11/26/2023 at about 4:30pm, V22 notified her that R13 was on the floor and her head was lying on the metal part of the bedside table. V21 said R13 is a high risk for falls and assessed her and sent her to the hospital. On 12/14/2023 at 10:35am V2 (Director of Nursing-DON) said that…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-07-01 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to notify family and the attending physician of a dental appointment with procedure scheduled outside of the facility. These failures affects one resident (R2) of three residents reviewed for family and physician notification for changes.Findings include:R2's Face Sheet states V4 and V22 are listed as POA (Power of Attorney) with V22 listed as the first emergency contact.R2's medical record documents R2 went out of the facility for a dental appointment on 6/1/26 and returned to facility. Staff could not control the bleeding from R2's gums. Emergency Response (911) was called and R2 was admitted to the hospital with a diagnosis of Oral Hemorrhage.On 6/9/26 at 11:45AM, V7 (Certified Nursing Assistant (CNA)/Supervisor/Scheduler) stated V7 recalls scheduling the dental appointment for R2 and informing a nurse but V7 could not recall who the nurse was.On 6/9/26 at 12:30PM, V8 (RN) stated it is the scheduler who schedules the appointments that will inform the family. V8 stated most of the time, the staff don't even know that 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.

  Resident Rights Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · E2026-05-08 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy by neglecting to provide the necessary personal care and assistance with ADLs (activities of daily living) to meet the residents needs. This failure affected all 30 residents residing on one nursing unit. Findings include:On 5/6/26 at approximately 3:00 PM, this surveyor and V1 (administrator) observed the facility's video surveillance tape, dated 5/2/2026. At 10:10 PM, the video shows V8 CNA (certified nurse aide) pulling into the facility parking lot. Video shows V8 enter the facility at 11:43 PM. At 1:51 AM, it shows V8 getting into her vehicle and leaving the facility. Video surveillance shows V8 return and enter the facility at 4:39 AM. At 05:51 AM, video surveillance show V8 leave the facility again and return at 5:59 AM.On 5/5/26 at 2:26 PM, V8 CNA stated that she was scheduled to work a double shift on 5/2/2026 11:00 PM- 5/3/26 3:00PM. V8 stated that it was only her and V38 (nurse) present on side 3 nursing unit during the 11:00 PM-7:00 AM shift due to a CNA…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Ecited before2026-05-08 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to follow its ADL ( Activities of Daily Living) policy and provide incontinence care and turning/repositioning for four residents ( R1, R10, R12, and R13) who are totally dependent on two staff for all ADL care, with the potential to affect all 30 residents residing on one nursing unit.Findings include: On 5/6/26 at approximately 3:00 PM, this surveyor and V1 (administrator) observed video surveillance, dated 5/2/2026. At 10:10 PM, the video shows V8 CNA (certified nurse aide) pulling into the facility parking lot. Video shows V8 enter the facility at 11:43 PM. At 1:51 AM, video surveillance shows V8 getting into her vehicle and leaving the facility. Video surveillance shows V8 return and enter the facility at 4:39 AM. At 05:51 AM, video surveillance show V8 leave the facility again and return at 5:59 AM.On 5/5/26 at 2:26 PM, V8 CNA (certified nurse aide) stated that she was scheduled to work a double shift on 5/2/2026 11:00 PM- 5/3/26 3:00PM. V8 stated that it was only her and V38 (nurse) present on side 3 nursing unit during…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · D2026-05-08 · tag F0657 — failed to keep the care plan current — isolated
  Develop 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

  Based on interview and record review, the facility failed to follow its fall prevention and management policy and review and revise one resident's care plan after each fall. The facility also failed to implement effective interventions to eliminate or reduce resident's fall risk. This failure affects one resident (R3) out of three reviewed for falls in a sample of 36.Findings include:On 5/6/26 at 11:50 AM, V18 (restorative nurse) stated that she reviews risk management for any resident falls and does rounds asking staff if any resident has fallen in the past 24 hours. V18 stated that V2 DON (director of nursing) will alert her about a resident fall. V18 stated that she investigates each fall. V18 stated that she asks the resident if alert enough, checks for any staff witnesses. V18 stated that during the daily morning meeting IDT (interdisciplinary team) will determine what new interventions should be put in place. V18 stated that she is responsible for updating the resident's falls care plan after each fall. When questioned about what fall interventions were put in place after R3'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.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · Ecited before2026-02-13 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, this facility failed to follow its call light policy and ensure the call light cord was within reach for 4 residents (R3, R5, R6, and R7) out of 4 residents reviewed for call light accessibility in a sample of 7. Findings include:On 2/13/26 at 9:45 AM, R3 was heard shouting hello from his room. This surveyor asked R3 if he needed assistance, R3 responded that he is uncomfortable sitting in the reclining chair and wants to go back to bed. R3 stated that he has been in this chair since 5:00 AM when he went to his dialysis treatment. R3's call light cord was observed between wall and folded floor mat behind head of bed. When questioned if he was able to use call light for assistance, responded yeah I can't find it. V2 DON (director of nursing) was called to R3's room. When V2 was asked where R3's call light cord was, V2 retrieved it from behind head of bed. V2 stated that the call light cord should be within R3's reach. On 2/13/26 at 11:45 AM, R5 was observed lying in bed. R5's call light cord was observed dangling on R5'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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, this facility failed to identify, evaluate and eliminate hazards, and provide adequate supervision to prevent an avoidable accident in accordance with current professional standards of practice for one residents (R4) out of three residents reviewed for avoidable falls in a sample of 7. Findings include:On 2/13/26 at 9:55 AM, R4 was observed lying on his right side on the floor near bathroom. R4's wheelchair was observed on the right side at the head of R4's bed. R4's bedside table was observed positioned in front of wheelchair. R4 was observed wearing regular socks instead of non-skid socks. R4 stated that he slid while walking to bathroom because of the socks he was wearing. This surveyor shouted out for assistance. V11 (nurse) came immediately to R4's room. V11 stated that she is not R4's nurse today but responded to the call for staff assistance. V11 obtained R4's vital signs and performed a head-to-toe assessment, R1 sustained an open area to his right lateral lower leg. V8 CNA (certified nurse aide) and V9 CNA came to R4'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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-13 · tag F0919 — failed to provide a working call system — isolated
  Make sure that a working call system is available in each resident's bathroom and bathing area.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and record reviews, this facility failed to maintain its call light system in good working condition for one resident (R3) out of four residents reviewed for working call lights in a sample of 7. Findings include:On 2/13/26 at 9:45 AM, R3 was observed sitting in a reclining chair next to the bed closest to the door. R3's call light cord was observed between wall and folded floor mat behind head of bed. When questioned if he was able to use call light for assistance, responded yeah I can't find it. V2 DON (director of nursing) was called to R3's room. When V2 was asked where R3's call light cord was, V2 retrieved it from behind head of bed. V2 handed R3 call light button and R3 was asked to demonstrate how to use it. R3 pressed the call light button; the light did not activate in hallway above R3's door. R3 was asked to press again, the light still did not activate. R3 was given the call light cord for the bed furthest from the door and asked to press call light button, the light was activated in hallway above door. V2 stated that R3's call light…

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

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-11-18 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and record reviews, the facility failed to follow its abuse prevention policy and notify the State Survey Agency within the required two-hour timeframe of allegations of abuse and injury of unknown origin for six residents (R1, R2, R3, R4, R5, and R9) out of seven residents reviewed for abuse in a sample of 10.Findings include:On 9/18/25 at 3:00 PM, V1 (administrator) reviewed the date and time allegations of abuse were known and the date and time the initial reports were sent to the State Survey Agency. V1 acknowledged that the initial reports for an allegation of abuse or an injury of unknown origin must be reported immediately but not more than two hours after allegation is known.1. R1's family member on 7/21/25 at 2:00 PM reported he observed bruising on R1's arm. When R1 was questioned, R1 stated that V4 CNA (certified nurse aide) had been rough during care for R1. An abuse investigation was initiated. The initial report was not sent to the State Survey Agency until 7/21/25 at 6:06 PM.2. On 9/18/25 at 11:23 AM, V5 RN (registered nurse) stated that she…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-11-18 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop 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 person-centered care plans for four residents (R1, R2, R3, and R4) identified as at risk for abuse out of four residents reviewed for abuse in a sample of 10. Findings include:On 9/18/25 at 1:00 PM, V9 SSD (social services director) stated that social services is responsible for initiating/updating care plans related to resident behaviors, mood, and cognitive status. V9 stated that social services is not responsible for completing an abuse care plan for residents. V9 stated that V9 does not know who is responsible for initiating/updating the abuse risk care plan.On 9/18/25 at 1:23 PM, V2 DON (interim director of nursing) stated that the nurses are responsible for initiating/updating nursing related care plans, such as resident diagnosis. V2 reviewed the abuse risk assessment completed for R2. V2 stated that social service did R2's abuse risk assessment. V2 stated that care planning required that appears next to the abuse risk assessment indicates a care plan needs to be done for that resident. V2 stated that V2…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-09 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  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 receiving psychotropic medications have a gradual dose reduction attempt or documented clinical contraindication for not attempting. This failure affects one resident (R77) of three reviewed for psychotropic medications. Findings include: R77's POS (physician order sheet), notes an order for Escitalopram (Antidepressant) 10mg (milligrams) oral daily for major depressive disorder, recurrent, moderate. R77 was admitted to this facility on 8/23/24. R77 transferred from another long term care facility. Those medical records note R77 was receiving escitalopram 10mg daily for major depressive disorder. On 5/8/25 at 5:10 PM, V2 DON (Director of Nursing) stated that V2 is unable to find any documentation in R77's medical record noting a GDR (gradual dose reduction) was done for Escitalopram medication. V2 stated that the purpose of GDR is to find optimal dose and to determine if the medication is helping resident. This facility's psychotropic and anti-psychotic medication policy, revised 04/2025, notes…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Fines & penalties

$521,548 in federal fines across 6 penalties. 2 Medicare payment denials on record.

• $68,510 — penalty dated 2026-01-23
• $135,502 — penalty dated 2025-05-09
• $33,040 — penalty dated 2025-01-15
• $14,050 — penalty dated 2024-12-18
• $161,680 — penalty dated 2024-04-08
• $108,766 — penalty dated 2023-12-19
• Medicare payment denial — starting 2025-06-06 for 56 days
• Medicare payment denial — starting 2024-05-07 for 55 days

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

Part of a chain

This home belongs to GENERATIONS HEALTHCARE NETWORK — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

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

Who owns this facility

CMS files one row per role, so the 8 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

This home reported $4.5M paid to related parties — landlords or management companies under common ownership — equal to about 31% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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