Southgate Health Care Center

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.

51.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 47.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 44 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 3% 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.

Staffing

How full it usually is: this home is certified for 140 beds and averages 91.9 residents a day — about 66% occupied, or roughly 48 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 3.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.38 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.445 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 3.35 hrs/resident/day on weekends vs 3.91 on weekdays — 14% thinner on weekends. RN hours go from 0.47 to 0.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above 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 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.

35 citations, most serious first. The 14 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · J2026-03-27 · 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 observations, interviews, and record reviews, the facility failed to provide effective pain management for 3 of 3 residents (R1, R2, and R3) reviewed for pain in a sample of 4. This failure resulted in R1, who has a diagnosis of Multiple Myeloma and at the end-of-life stage, not receiving an ordered narcotic pain medication for 6 hours and R1 experiencing intense pain and suffering prior to her death.This failure resulted in Immediate jeopardy, which was identified to have begun on [DATE] when the facility ran out of R1's oral Dilaudid pain medication resulting in R1 experiencing uncontrolled pain. V1 (Administrator), V21 (Regional Clinical Coordinator), V2 (Director of Nursing, and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 2:10PM. The immediacy was removed on [DATE], but non-compliance remained at a Level Two because additional time is needed to evaluate the implementation and effectiveness of In-service training.Findings Include:1.R1's admission Record…

  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
• Immediate jeopardy · J2023-04-14 · 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 recognize the urgency of a worsening wound and seek immediate evaluation and treatment after noting a significant change in the condition of the wound for 1 (R38) of 7 residents reviewed for wound care in a sample of 77. This failure resulted in R38 developing gas gangrene with underlying osteomyelitis requiring emergent trans-metatarsal amputation and subsequent Chopart's (forefoot and midfoot) amputation and R38 has been placed on hospice care. The Immediate Jeopardy began on [DATE] when R38 was observed to have a significant change to an existing necrotic wound of the left 2nd toe. The new, necrotic area was observed starting between the previous necrotic left 2nd toe, migrating over between the left great toe and down to the bottom of the left foot. V1 (Administrator) and V2 (Director of Nursing/DON) were notified of the Immediate Jeopardy on [DATE] at 1:55pm. The surveyor confirmed by interview and record review that the Immediate…

  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 before2024-10-17 · 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 safely transfer 4 (R1, R2, R3, R11) of 5 residents reviewed for transfers in a sample of 11. This failure resulted in R1 sustaining a large hematoma to the chest wall and requiring a 5-day hospitalization in the Special Care Unit for monitoring and pain management. Findings include: 1. R1's document titled admission Record documents an admission date of 2/28/2024 and includes diagnoses of fracture of femur, Atherosclerotic Heart Disease, Hyperlipidemia, Abnormal Posture. R1's MDS (Minimum Data Set) dated 9/9/2024 includes a BIMS (Brief Interview for Mental Status) score is 5 indicating sever cognitive impairment. Section GG of MDS documents Functional Limitation in Range of Motion R1 has impairment to both sides of upper extremities, and impairment on one side of Lower extremity. Mobility devices used is a wheelchair. Documentation includes R1 is Dependent for Bed mobility, sit to lying, lying to siting on side of bed, sit to stand, chair…

  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 · G2024-09-26 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to monitor weights and implement interventions to prevent weight loss for 1 of 3 (R3) residents reviewed for nutrition in a sample of 8. This failure resulted in R3 sustaining 9.5% weight loss in less than 1 month and. a 14% weight loss in less than 3 months. Findings include: R3's admission Record documents an admission date of 9/6/2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Mild protein-calorie malnutrition, Pulmonary Hypertension, Parkinson's Disease, and Repeated Falls. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13 indicating R3's cognition is intact. Section GG, Functional Abilities, indicates R3 requires set up or clean up assistance with eating. Section K, Swallowing/Nutritional Status, documents that R3 weighs 180 lbs, R3 has had a gain of 5% or more in the last month or a gain of 10% or more in the last 6 months, and R3 is not on a…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-29 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide dependent residents timely ADL (Activities of Daily Living) assistance with toileting/incontinence care for 1 of 3 residents (R1) reviewed for ADL assistance in the sample of 11. R1's admission Record (print date 6/24/26) documented an original admission date of 8/2/23 and included diagnoses of cognitive deficit due to cerebral infarction, Alzheimer's disease, anemia, arthritis, cognitive communication deficit, and repeated falls.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 has severe cognitive impairment. This MDS documents R1 is frequently incontinent of urine and bowel, is dependent upon staff for toileting hygiene, and R1 needs substantial/maximum assistance for toilet transfer. R1's most current Care Plan documents R1 has an ADL self-care performance deficit related to Alzheimer's, impaired balance, and limited mobility (initiated on 10/23/24, revised…

  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 before2026-06-02 · 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 a medical provider of abnormal vital signs for 1 (R1) of 3 residents reviewed for change in condition in a sample of 6.Findings include:R1's admission Record documented an admission date of 3/19/24 with diagnoses including Parkinson's disease, dementia, and anxiety disorder. R1's 5/8/26 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 was severely cognitively impaired.R1's 5/19/26 at 12:30 AM progress noted authored by V6 (Licensed Practical Nurse/ LPN) documented in part . BP (Blood Pressure) 89/82, P (Pulse) 45, R (Respirations) 20, T (Temperature) 102.3 (degrees Fahrenheit), O2 (Oxygen Saturation) 90 (90%) . Sweating, shallow breathing, bilat (bilateral) arm tremors noted. Pupils equal reactive to light and accommodation. Minimal repose when addressing, no words given, only audible gasps made. Tylenol 500 mg given, fluids encouraged.R1's 5/19/26 at 6:12 AM progress note documented in part .: BP 113/84, P 62, R 17, T 98.1, O2 93. Sweating, shallow breathing,…

  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 before2026-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interventions, and record reviews, the facility failed to provide appropriate incontinence care and oral care to 3 (R1, R2, R3) of 4 residents reviewed for Activities of Daily Living (ADL's) in a sample of 4. Findings include:.1. R2's admission Record documents an admission date of 2/26/2022 and includes diagnoses of Multiple Sclerosis, local Infections of the skin and subcutaneous tissue, Type 2 Diabetes Mellitus, Paralytic Syndrome following Cerebrovascular Disease, Convulsions, Major Depressive Disorder, and Dysphagia. R2s Physician Order sheet documents R2 was placed on hospice on 2/27/26.R2's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 12 suggesting moderate cognition impairment. Section GG documents R2 is dependent for all activities of daily living including oral care. Section H- Bladder and Bowel documents R2 has an ileostomy, and is always incontinent of bowel, and urinary continence is not rated. R2's Care Plan documents R2 has…

  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 · Fcited before2026-01-27 · tag F0755 — failed to provide safe pharmacy services — widespread
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to ensure authorized licensed personnel administered medications and failed to ensure accurate documentation of the personnel administering the medications. This failure has the potential to affect all 91 residents residing in the facility.Findings include: On 1/16/26 at 11:16 AM, V1 (Administrator) presented surveillance footage from the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified Nursing Assistant/ CNA) is observed pulling the keys to the medication cart and the medication room out of her pocket, opening the medication cart, popping medications into medication cups, taking the medication cups to resident rooms for administration, and opening the medication room door without a nurse present. V5 is observed to be documenting medications administered on a facility laptop computer. V1 said V5 did not have a log in for the Electronic Medical Record (EMR) and was unsure how V5 was documenting the medications.On 1/16/26 at 12:24 PM, V1 presented video surveillance footage of 1/15/26…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-01-27 · tag F0761 — failed to label and store drugs safely — widespread
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to only permit authorized individuals access to drugs, biologicals, and controlled Schedule II drugs. This failure has the potential to affect all 91 residents residing in the facility. Findings include:On 1/16/26 at 11:16 AM, V1 (Administrator) presented surveillance footage from the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified Nursing Assistant/ CNA) is observed pulling the keys to the medication cart and the medication room out of her pocket, opening the medication cart, popping medications into medication cups, taking the medication cups to resident rooms for administration, opening the schedule II controlled medication box, popping schedule II medications into medication cups, signing out schedule II medications in the schedule II count binder, and opening the medication room door without a nurse present.On 1/16/26 at 12:24 PM, V1 presented video surveillance footage of 1/15/26 with the time stamps as follows: 9:04 PM showing V5 taking a cup of medications to R1's room, 9:11 PM…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-01-27 · tag F0839 — widespread
  Employ staff that are licensed, certified, or registered in accordance with state laws.
  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 employees working as a licensed staff member had an active professional license. This failure has the potential to affect all 91 residents residing in the facility.Findings include:On 1/16/26 at 11:16 AM, V1 (Administrator) presented surveillance footage from the night of 1/15/26 from 8:00 PM through 9:20 PM. In the footage V5 (Certified Nursing Assistant/ CNA) is observed pulling the keys to the medication cart and the medication room out of her pocket, opening the medication cart, popping medications into medication cups, taking the medication cups to resident rooms for administration, opening the schedule II controlled medication box, popping schedule II medications into medication cups, signing out schedule II medications in the schedule II count binder, and opening the medication room door without a nurse present.On 1/16/26 at 12:24 PM, V1 presented video surveillance footage of 1/15/26 with the time stamps as follows: 9:04 PM showing V5 taking a cup of medications to R1's room, 9:11 PM V5 taking 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-01-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review the facility failed to maintain safe water temperatures for 3 residents of 12 (R10, R11, R12) reviewed for water temperatures in the sample of 12. This failure has the potential to affect 45 confused and ambulatory residents of the 90 residents residing in the facility.Findings include:On 1/20/26 at 1:35 PM, a digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit.On 1/20/26 at 1:50 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the hand sink of the A hall shower room registered 121.4 degrees Fahrenheit (F). At that time the A hall hot water heater mixing valve was set at 104 degrees Fahrenheit.On 1/20/26 at 2:18 PM, the hot water temperature taken with a calibrated digital metal stemmed thermometer was taken at the hand sink of the 200-hall shower room registered 128.0 degrees F and slowly dropped below 110 degrees F after approximately one minute. At 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 · F2025-11-19 · tag F0925 — failed to control pests — widespread
  Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to maintain the kitchen free from roaches. This failure has the potential to affect all 94 residents residing in the facility.Findings include:On 11/18/25 at 10:25 AM, a cockroach was crawling across the back of the hand washing sink in the kitchen.On 11/18/25 at 10:33 AM, a cockroach was crawling along the wall under the 3-compartment sink in the kitchen.On 11/18/25 at 11:28 AM, two cockroaches were crawling along the wall next to the three-compartment sink in the kitchen.On 11/18/25 at 10:28 AM, V3 (Cook) said the kitchen had a lot of cockroaches and had been trying to get rid of them since V3 started in January of 2025. V3 said a pest control company would come to the facility once a month and the cockroach problem would get better, but they would slowly return. V3 said staff tried to keep the kitchen as clean as possible to decrease the cockroach population.On 11/18/25 at 3:50 PM, V4 (Chief Executive Officer) said the dietary manager should have told us there were roaches in the kitchen and he would have…

  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 · D2025-05-30 · 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 observation, interview, and record review, the facility failed to ensure life sustaining measures were initiated to 1 (R1) of 3 residents reviewed for Cardio-Pulmonary Resuscitation (CPR) in a sample of 6. The findings include: R1's admission Record documents an admission date of [DATE] with diagnoses including Encounter for Palliative Care, Chronic Pain Syndrome, Amyotrophic Lateral Sclerosis (ALS), Anxiety, Major Depressive Disorder. Special instruction document Residential Hospice of Southern Illinois. R1's Hospice Initial Plan of Care dated [DATE] documents a start of care date of [DATE] with a Terminal Diagnosis of Amyotrophic Lateral Sclerosis (ALS). This same document is marked yes under the category of DNR (Do Not Resuscitate). R1's facility Care Plan documents a Focus area of R1's wish is to be resuscitated and CPR to be initiated if his heart stops with an initiation date of [DATE]. Interventions documented include: all staff should perform Heimlich maneuver if choking and proceed with CPR,…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-04-18 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection control practices while providing incontinence care and handling contaminated linens for 2 (R19 and R23) of 8 residents reviewed for incontinence and contact precautions. Findings include: 1. R19's admission Record documented an admission date of 6/3/2021 and included diagnoses of methicillin staphylococcus aureus infections as the cause of the diseases classified elsewhere, osteomyelitis unspecified, vasculitis limited to the skin unspecified, and major depressive disorder, single episode, unspecified. R19's Quarterly Minimum Data Set (MDS) dated [DATE] documented R19 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R19 is cognitively intact. R19's MDS Section for Functional Abilities and Goals documented impairment under range of motion in her lower extremities on both sides. R19's MDS Section for Active Diagnoses documented R19 having an Infection of a Multidrug-Resistant Organism (MDRO).…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$20,170 in federal fines across 2 penalties. 1 Medicare payment denial on record.

• $12,761 — penalty dated 2024-09-13
• $7,409 — penalty dated 2023-12-11
• Medicare payment denial — starting 2026-04-09 for 8 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.

Who owns this facility

CMS files one row per role, so the 20 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

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