Piatt County Nursing Home
1111 N State St, Monticello, IL 61856 · Government - City/county · 100 certified beds · (217) 762-2506 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0609) — most recent Apr 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $182,948 in federal fines (most recent 2025-05-05)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.7% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 8.1% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 6.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.4% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.9% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.3% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 26.0% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.7% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.4% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 22.2% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.7% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 9.3% | 2.2% | 1.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.01 | 2.02 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.77 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 100 beds and averages 85.5 residents a day — about 86% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.15 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.95 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.46 hrs/resident/day on weekends vs 4.43 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.39 to 0.23 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%.
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.
32 citations, most serious first. The 16 most serious are shown; the remaining 16 are one tap away and print in full.
- Immediate jeopardy · Kcited before2024-04-09 · tag F0609 — failed to report abuse allegations — patternTimely 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 observation, interview, and record review the facility failed to report repetitive instances of verbal and physical abuse of a resident (R45) by V13 Certified Nurse's Assistant and failed to report a resident to resident physical altercation to the facility's Administrator. These failures resulted in V13 having continued access to R45 in which V13 provided direct cares and in the further instances of verbal and physical abuse of R45 by V13. As a result of this abuse R45's hands and chest were bruised and R45 displayed emotional symptoms of residual harm as evidenced by flinching(making sudden startled movements) and increased behaviors with cares. These failures affected three (R45, R35, and R69) of six residents reviewed for abuse on the sample list of 47. This failure has the potential to affect all 24 residents (R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32) residing on the Dementia unit. These Failures resulted in an immediate jeopardy. The Immediate Jeopardy began on 1/9/24 when V16 Certified…
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.
- Immediate jeopardy · J2024-04-09 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the right to be free from physical and verbal abuse by staff. R45, who resides on the dementia unit, was subjected to physical and verbal abuse on three separate occasions by V13 Certified Nurse's Assistant. R45's hands and chest were bruised, R45 was fearful showing emotional symptoms following the incidents as evidenced by increased behaviors with cares, making more sudden abrupt startled movements when approached by caregivers. These failures affect one (R45) of six residents reviewed for abuse on the sample list of 47. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/9/24 when V13 Certified Nurse's Assistant verbally abused R45 during a shower, V13 was suspended from work 3/13/24. V1 Administrator was notified of the Immediate Jeopardy on 4/4/24 at 10:00 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 4/4/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-05-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent an injury by failing to ensure a bed was in a low position for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 sustaining a laceration to the right forearm, a hematoma, and spinal fracture which required emergency medical treatment. Findings include: The facility's Managing Falls and Fall Risk Policy with a revision date of 12/2021 documents that staff will identify and implement relevant interventions to try to minimize serious consequences of falling. R1's Care Plan initiated on 9/3/2019 documents that R1 was at risk for injury related to mobility status. This Care Plan documents that R1 has a history of skin tears, bruises, and a history of falls. This Care Plan documents an intervention for the bed to be in the lowest, most appropriate position when resident is resting in bed. R1's Incident report dated 4/14/2025 documents R1 was found on the floor next to the bed at 10:40 PM by V9,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited beforedisputed · IIDR2025-02-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to provide safe and effective supervision during a total body mechanical lift transfer to prevent a traumatic fall. This failure resulted in R1 falling from R1's transfer sling, striking R1's head on an adjacent bedside table, and landing on the floor, resulting in a collarbone fracture and scalp laceration requiring emergency medical treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: R1's medical diagnosis list dated 2/6/25 documents R1's diagnoses include: Neuropathy, Left Knee Pain, Hyperlipidemia, Arthritis, Anxiety, and Depression. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severely impaired cognition and is totally dependent on staff for transfers. On 2/10/2025 at 09:50 AM, V4 Certified Nursing Assistant (CNA) and V5 Certified Nursing Assistant reported R1's transfer is supposed to be completed by two staff members using the total body mechanical lift. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-05-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to properly perform and complete catheter care, and maintain urinary drainage collection chambers off of the floor. The facility also failed to treat and complete physician ordered recommendations after the development of a penile wound for two of three residents (R53 and R52) reviewed for indwelling catheter use on the total sample list of 39. This failure resulted in R53's penile wound worsening and becoming split from the urethral opening to the scrotal sac area. Findings include: 1) R53's medical record documents the following diagnosis: Retention of Urine, Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms. On 5/8/23 at 1:26 PM R53's urinary drainage collection chamber bag was laying on the floor at the end of the bed. R53's medical record did not contain a comprehensive care plan for the use of an indwelling urinary drainage device or a comprehensive care plan after the development of the wound to R53's penis. R53's medical record documents on 2/8/23, (V10 Wound Physician) here on 2/6/23 to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2023-05-11 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to identify significant weight loss, notify the physician and Registered Dietitian, implement nutritional interventions, complete nutritional assessments, and record nutritional supplement intake for two (R13, R16) of four residents reviewed for nutrition in the sample list of 39. These failures resulted in R13 experiencing an additional significant weight loss of 6.65 % in one month. Findings include: The facility's Impaired Nutrition/Unplanned Weight Loss Clinical Protocol revised October 2020 documents the nursing department are responsible for monitoring resident weights. Significant weight loss is identified as a loss of at least 5% in one month, 7.5 % in 3 months, and 10 % in 6 months. The physician will review possible causes of weight loss. Interventions will be implemented to address weight loss. The Dietitian and Physician will determine the resident's diet including if nutritional supplements need to be added. Monitoring weight…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-18 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to label insulin, eye drops, and nose spray containers with the date opened for three of eighteen residents (R24, R33, R46) reviewed for medication administration on a sample list of 39. B. Based on observation, interview, and record review the facility failed to discard expired insulin for two of eighteen residents (R3, R68) reviewed for medication administration on a sample list of 39. Findings include: a. The facility's Storage of Medications Policy dated 2023 documents that all injectable medications, eye drops, nose spray, ear drops, liquid medications shall be labeled with date upon opening containers. R24's Medication Administration Record (MAR) dated [DATE] documents R24 is receiving Fluticasone Propionate nose spray. R33's MAR dated [DATE] documents R33 is receiving Dorzolamide HCl-Timolol eye drops. R46's MAR dated [DATE] documents R46 is receiving Lantus…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-18 · tag F0880 — failed to prevent and control infections — patternProvide 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 use required personal protective equipment during the transfer of a resident on contact isolation and failed to prevented cross contamination during incontinence care and urinary catheter care for three of four residents (R26, R68, R76) reviewed for infection control on the sample list of 39. Findings Include: 1. R26's Physician Order dated June 2025 documents R26 is to be on contact isolation related to Methicillin-Resistant Staphylococcus Aureus (MRSA) of the foot. On 6/17/25 at 8:45 AM V8 Certified Nurse's Assistant (CNA) and V18 CNA transferred R26 using a full mechanical lift. R26 was on contact isolation for Methicillin-Resistant Staphylococcus Aureus (MRSA) of the right foot. Neither V8 nor V18 wore gowns during the transfer. On 6/17/25 at 9:00 AM V2 Director of Nurses confirmed R26 is on contact isolation related to MRSA of his foot and both V8 and V18 should have been wearing both gloves and gowns during the transfer. The undated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-18 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain dignified quality of life for one of one resident (R68) reviewed for dignity on the sample list of 39. Findings Include: The facility's Quality of Life - Dignity policy revised in 2024 documents each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff should always treat resident with respect and dignity. Treating with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that compromise dignity are prohibited. Staff should promote dignity and assist residents as needed by promptly responding to a resident's request for toileting assistance (incontinence care). R68's Medical Diagnoses List dated June 2025 documents R68 is diagnosed with Diarrhea, Legal Blindness, Age-related physical debility, and Depression. R68's Minimum Data Set, dated [DATE] documents R68…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 maintain call lights within reach for one of one resident (R68) reviewed for call lights on the sample list of 39. Findings Include: The facility's Call Light Policy dated October 2010 documents when residents are in bed or confined to a chair staff are to make sure the call light is within easy reach of the resident. R68's Medical Diagnoses List dated June 2025 documents R68 is diagnosed with Diarrhea, Legal Blindness, Age-related physical debility, and Depression. R68's Minimum Data Set, dated [DATE] documents R68 has some cognitive impairment, uses a wheelchair, is always incontinent of bowel and bladder, and is dependent on staff for toileting hygiene and transfers. R68's Care Plan dated 9/25/24 documents R68 is at risk for skin breakdown, is legally blind, and staff are to place the call light within easy reach, place frequently used personal items within easy reach and respond to requests for assistance promptly. R68 is at risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-18 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 record review and interview, the facility failed to provide a notice of bed hold to a resident being discharged to a local hospital. This failure affects one resident (R11) out of one reviewed for hospitalization on the sample list of 39. Findings include: R11's Census Detail dated 6/18/25 documents R11 was hospitalized starting on 8/20/24 through 8/26/24. R11's comprehensive Electronic Medical Record did not contain a notice of bed hold provided to R11. On 6/17/25 at 9:17 AM, R11 stated she had been to the hospital several times for various reasons. R11 further stated she did not remember anyone telling her anything about being able to come back to the facility nor that the facility would hold a bed for her. R11's Minimum Data Set, dated [DATE] documents R11 received a score of 15 out of a possible 15 during a Brief Interview for Mental Status indicating R11 is cognitively intact and without memory recall problems. On 6/17/25 at 3:50 PM, V3, Administrative Assistant, stated there was not a bed hold…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-18 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to transmit minimum data set resident assessments for significant change in status, and discharge, in the required time frame. These failures affect one resident (R5) out of one reviewed for minimum data set transmissions on the sample list of 39. Findings include: R5's Minimum Data Set for significant change in status dated as completed 5/16/25 did not document any transmitted or accepted date. R5's Minimum Data Set for discharge with return anticipated, likewise dated as completed 5/16/25, did not document any transmitted or accepted date. The Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 documents these minimum data sets for R5 are required to be transmitted within 14 days of the completion date. On 6/17/25 at 1:58 PM, V5, Minimum Data Set Assistant, stated he was not sure about the timing requirements for the Minimum Data Sets as he was new to his position. On 6/17/25 at 2:00 PM, V19, Dementia Unit Coordinator/ Dementia Unit Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-04-09 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to monitor and maintain Certified Nursing Assistant (CNA) required twelve hours of inservice training per year to ensure continued competence. This failure has the potential to affect all 82 residents residing in the facility on the sample list of 47. Findings include: V20's training record documents, V20's Continuing Education Hours completed for 2023 total 7.00 hours. V27's training record documents, V27's Continuing Education Hours completed for 2023 total 11.50 hours. V28's training record documents, V28's Continuing Education Hours completed for 2023 total 11.50 hours. On 4/04/24 at 10:15 AM, V2 Director of Nursing states V2 is aware of the required Certified Nursing Assistant (CNA) requirement of 12 hours of annual education. V2 indicates V15, Wound Nurse, is responsible for monitoring CNA education and informing those CNA's that are in need of completing education hours. V2 acknowledges V2 and V15 are aware that several CNA's do not have the required 12 continuing education hours for 2023. V2 confirmed V20, V27, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-04-09 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to follow it's abuse prohibition policy by failing to report allegations of abuse to the facility Administrator and prevent further resident abuse. These failures affected three (R45, R35, and R69) of six residents reviewed for abuse on the sample list of 47. These failures have the potential to affect all 24 residents (R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32) residing on the Dementia unit. Findings include: The facility's Abuse Prohibition policy dated 8/22/16 documents all residents have the right to be free from verbal and physical abuse. This policy documents the definition of physical abuse as, the infliction of injury on a resident that occurs other than by accidental means. This policy documents the definition of verbal abuse as, the use by an employee or agent of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the dignity of one (R57) of four residents reviewed for dignity in a sample list of 47 residents. Findings include: R57's Minimum Data Set (MDS) dated [DATE] documents R57 as cognitively intact. R57's Final Incident Report to the State Agency dated 4/3/24 documents R57 reported V19 Certified Nurse Aide (CNA) used the 'F' (expletive) word and it is offensive to women. On 4/1/24 at 10:00 AM, R57 stated, There is a male CNA (V19) that comes in my room and uses the 'F' (expletive) word like it is okay to say that. (V19) always brings in another female CNA in with him. (V19) says things like 'F* (expletive) this and f* (expletive) that' when he talks to the other CNA and when he talks to me. It is very disrespectful. First of all, I do not require two CNA's to help me with anything. Second of all, I do not allow the use of the 'F' (expletive) word from anyone. I have told (V19) not to say that but he continually does. On 4/3/24 at 10:30 AM, V1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 access to a hand washing sink for two residents (R21, R12) of 18 residents reviewed for accommodation of needs in a sample list of 47. Findings Include: 1. R21's electronic health record diagnosis list, printed on 4/3/24 at 3:05 PM, documents the following diagnoses: Chronic Obstructive Pulmonary Disease, History of Falling, Right Knee Pain, Abnormal Gait and Mobility, Unsteadiness on Feet, Neuropathy, Muscle Weakness, and Anxiety Disorder. R21's Minimum Data Set, dated [DATE] documents R21 is cognitively intact and uses a wheelchair for mobility. On 4/2/24 at 4:00 PM, R21 stated I have to use the sit-to-stand lift to go to the toilet and it's tight in there, but we manage. I'd really like to use the sink to wash my hands and face, comb my hair and brush my teeth, I can't get my wheelchair anywhere close to the sink. I like to do as much as I can for myself. The sink is observed to be between a wall and a cabinet and does not 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.
Show the remaining 16 citations
- Potential for harm · Dcited before2024-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent falls by ensuring a residents personal safety alarm was in working order, using an inappropriate sized mattress on a residents bed and failed to ensure a residents fall interventions were in place. This failure affects three (R19, R35, and R27) of five residents reviewed for falls on the sample list of 47. Findings include: 1.) R19's nurse's notes written by V4 Licensed Practical Nurse dated 3/10/24 at 2:41 PM, documents R19 was found on the floor laying on her stomach. R19 was noted to have a contusion above the right eyebrow. R19 was sent to the emergency room for an evaluation. On 4/02/24 at 11:43 AM, V4 stated on 3/10/24 she had just got done with lunch and she heard someone say that someone was on the floor. V4 stated she ran out there and R19 was laying on the floor on her side and the right side of her face was bleeding. V4 stated she sent her our due to her being on a blood thinner. On 4/2/24 at 11:49 AM, V5 Activity Aide…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to support the appropriate use of psychopharmacologic medications for residents, failures include: completing residents' psychotropic medication assessments, determine the cause of residents' behaviors considering nonpharmacological interventions, providing parameters for the use of as needed (PRN) antianxiety medication, and providing a rational for duplicative therapy nor required gradual dose reductions for residents receiving psychotropic medications. These failures affects two (R19, R28) of six residents reviewed for psychotropic medication use on the sample list of 47. Findings include: The facility's psychotropic medication policy dated 03/2021 states, 2. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-09 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to implement antibiotic stewardship practice for residents by ordering prophylactic antibiotics. This failure affects two residents (R60, R35) reviewed for antibiotic stewardship on the sample list of 47. Findings Include: R35's Physician's Order Summary dated 4/3/24 includes a physician's order for Cephalexin Oral Tablet 250 MG (Cephalexin) Give 1 tablet by mouth one time a day for Urinary Tract Infection. This order is documented as initiated 6/17/23 and has been given continually since that date. R35's March Medication Administration Record (MAR) documents (R35) was given Macrobid Oral Capsule 100 MG 1 capsule by mouth two times a day related to Urinary Tract Infection from 3/3/24 to 3/21/24 . There is no documentation to support a Urine Culture and Sensitivity has been performed in the entire time (R35) has been given these antibiotics. There is no documentation to support (R35) has a physician's order to be evaluated by a Urologist the entire time (R35) has been given these antibiotics. R60's Physician's Order Summary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-11 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to document an investigation of resident's grievances and failed to notify residents of mitigation/resolution of the grievances as outlined in the facility's Grievance policy. This failure affects nine (R14, R57, R42, R62, R69, R23, R17, R60, R61) residents and has the potential to affect all 83 residents residing at the facility. Findings Include: The facility's Grievance Policy dated August 2018 states It is the policy of (the facility) that each resident has the right to voice to the facility or other agency that hears grievances without fear of discrimination or retaliation. The policy further states An investigation will commence, comprised of a review of the complaint, interviews with appropriate persons and witnesses, review of the medical record as appropriate, a permitted search of the resident's room and surrounding area, and a root cause analysis of all circumstances surrounding the incident. This will be completed utilizing the Grievance Investigation Form. (The facility) will ensure prompt resolution of all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, the facility failed to maintain sanitary food cooking areas. These failures have the potential to affect all 83 residents in the facility. Findings include: On 5/08/23 at 9:11 AM, V13 Assistant Dietary provided a tour of the kitchen where residents food is prepared. During the tour, accumulated dust was covering the vents and the recessed lights cages above the above the cooking range and griddle. Grease and food particles was covering the edges of the fryer. Floating particles of food was floating in the oil in the fryer. The fryer was on. V13 stated it was supposed to be cleaned yesterday and they were getting ready to make chicken strips in the fryer. On 5/9/23 at 9:54 AM, the dust on the vents and the recessed light cages above the range and griddle was still present. The resident census and condition report dated 5/8/23 documents there are 83 residents residing in the facility.
- Potential for harm · E2023-05-11 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 observation, interview, and record review the facility failed to develop a care plan for urinary catheter, edema, and wounds for three (R52, R45, R16) of 18 residents reviewed for care plans in the sample list of 39. Findings include: The facility's policy, with a revision date of December 2016, titled Care Plans, Comprehensive Person-centered documents, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8- The comprehensive, person centered care plan will: g- Incorporate identified problem areas. k- Reflect treatment goals, timetables and objectives in measurable outcomes. 10- Identify problem areas, their causes, and developing interventions that are targeted and meaningful to the resident. 13- Assessments of residents are ongoing and care plans are revised as information about the resident and the residents condition change. 1.) On 5/08/23 at 9:39 AM R52 was lying in bed and R52's urinary catheter collection bag was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-05-11 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to identify targeted behaviors, implement interventions, complete assessments, attempt gradual dose reductions and/or justify the duplicity of psychotropic medications for four residents (R52, R53, R66, and R75) of five residents reviewed for psychotropic medications in a sample list of 39 residents. Findings include: The facility's Psychotropic Medication Policy and Procedure dated March 2021 documents to determine underlying causes of behaviors to implement appropriate treatment including environmental, medical, and/or behavioral interventions. The physician should document the rationale and diagnosis for psychotropic use and identify targeted symptoms. Gradual dose reductions will be attempted in two separate quarters and annually thereafter unless clinically contraindicated. The interdisciplinary team will review the use of psychotropic medications quarterly and determine targeted behaviors and adverse effects. 1.) R66's Physician's Order Summary printed 5/10/23 includes the following orders for psychotropic medications:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-11 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to ensure one resident (R22) was treated with dignity during dining. R22 was one of two residents reviewed for dignity in the sample list of 39. Findings include: The Resident Council Meeting Minutes dated 4/10/23 document residents had concerns about Certified Nursing Asssistants (CNAs) using their cellular phones in the dining room during meal times. On 05/09/23 at 12:13 PM V26 CNA was sitting with R22 in the assisted dining room. R22 had R22's meal tray. V26 was typing on V26's personal cellular phone. On 5/9/23 at 3:26 PM V2 Director of Nursing stated employees are not to be using cellular phones when assisting residents. We have one CNA, V26, who we have repeatedly talked to about cellular phone usage. The facility's Quality of Life- Dignity revised August 2009 documents: Residents shall be treated with dignity and respect at all times.
- Potential for harm · D2023-05-11 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 assess for the ability to self administer medications and keep medications at the bedside for one resident (R27) reviewed for self administration of medications in the sample list of 39. Findings include: R27's medical record does not document an order for petroleum jelly treatment or to self administer Tums. There is no completed assessment in R27's medical record for the ability to self administer medications. R27's care plan revised on 3/26/23 does not document R27 may keep medications at the bedside and self administer medications. On 5/8/23 at 9:43 AM there was a bottle of Tums 1000 mg tablets and jar of petroleum jelly on R27's overbed table. On 5/9/23 at 12:22 PM the Tums and petroleum jelly were on R27's overbed table. R27 stated R27 applies the petroleum jelly to dry skin and takes the Tums as needed. On 5/09/23 at 12:30 PM V2 Director of Nursing (DON) stated residents have to have a physician's order to self administer medications and keep medications at the bedside. V2 confirmed R27 does not have an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview and record review the facility failed to ensure a sanitary and homelike environment for one (R69) of 24 residents reviewed for homelike environment on the sample list of 39. Findings include: On 5/08/23 at 10:50 AM, R69 stated they don't empty his urinal. R69's urinal was half full of urine and was sitting on the bedside table next to a banana and granola bar. R69 stated I wish there was another spot to put that. On 5/08/23 at 1:45 PM, R69's urinal was sitting on the bedside table. R69's urinal was a quarter full of urine. R69's water pitcher was sitting next to the urinal. R69's care plan dated 4/12/22 documents R69 had deficits in Activities of Daily living due to Parkinson's disease. On 5/10/23 at 12:43 PM, V2 Director of Nursing stated the staff should be emptying R69's urinal and ensuring it is not placed by food or water.
- Potential for harm · Dcited before2023-05-11 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 interview and record review the facility failed to notify the state agency, local law enforcement, and adult protective services of an allegation of sexual abuse for one of one residents (R7) on the sample list of 39. Findings include: On 5/08/23 at 11:50 AM, R7 stated a Certified Nurse's Assistant (V27) stroked his penis a couple times in the shower room before the water was even on. R7 stated V27 no longer gets to work on R7's hallway. R7 stated the Administration of the facility has talked to him about it. On 5/8/23 at 1:13 PM, V1 Administrator stated a concern was brought to me that V27 had touched R7 inappropriately in the shower. V1 stated V1 interviewed V27 along with V16 (Social Service Director) and R7 stated he didn't have any problems. V1 stated then I asked R7 outright if he had a sexual encounter with a V27 in the shower room and he said yes it was with V27, so I asked what happened and he said that V27 stroked his penis twice while washing him and it made him feel uncomfortable. V1 stated V27 told me it happened 4 to 6 months ago and that V27 didn't have a lot…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, interview and record review the facility failed to provide activities of daily living assistance for shaving for three of 18 residents (R46, R53, R54) reviewed for activities of daily living on the total sample list of 39. Findings include: 1) On 5/8/23 at 10:40 AM R46 was sitting up in wheelchair in room, R46 had stubble covering R46's bilateral cheek area, upper lip and chin area. R46 stated, I shave myself, they give me the stuff, I am not sure when I did last. On 5/9/23 at 10:00 AM R46's continued to have stubble covering R46's cheek area, upper lip and chin areas. R46's care plan documents, R46 has activities of daily living deficits related to Congestive Heart Failure, Diabetes, Obesity, Anemia, Chronic Kidney Disease, Anxiety and Depression. R46's MDS (Minimum Data Set) assessment dated [DATE] documents, R46 requires supervision with set up help for personal hygiene. 2) On 5/8/23 at 10:36 AM, R53 was lying down in bed, R53 had long stubble covering R53's bilateral cheek area, upper…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-11 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to obtain a treatment order upon identification of a wound for one resident (R45) of two reviewed for skin conditions in the sample list of 39. Findings include: On 5/08/23 at 11:35 AM there was a dressing on R45's forearm dated 5/6/233. R45 stated the wound started a few weeks ago as a dime size and is getting bigger. R45 was not sure what caused the wound. R45 stated the nurses didn't start changing the dressing regularly until a few days ago. On 5/10/23 at 11:01 AM V30 Licensed Practical Nurse administered R45's wound treatment. R45 had a large, circular, pink, moist wound to the right forearm. On 5/09/23 at 3:07 PM V3 Infection Preventionist stated R45 did not know what caused the wound. Initially we thought R45 scraped R45's arm on the full mechanical lift sling, like an abrasion. V10 Wound Physician took a biopsy of the wound and thinks it may be skin cancer. V3 stated V3 was the first person to document on the wound. R45's Skin & Wound Evaluation dated 4/28/23 documents R45 has a new abrasion to the right…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to reduce the risk for falls by failing to ensure the wheels on a bed were locked, the mattress on the bed did not slide, and a cushion on a wheelchair did not slide for two (R69) of three residents reviewed for falls on the sample list of 39. Findings include: R69's care plan dated 4/20/22 documents R69 is at risk for injury related to Parkinson's Disease. R69's fall risk assessment dated [DATE] documents R69 is at high risk for falling. On 5/8/23 at 11:30 AM, R69 was sitting on the edge of his bed. R69 stated his wheelchair is not comfortable and the cushion slides. R69 stated my mattress slides around on bed frame too. R69 stated the wheels on my bed are not locked. R6 stated, I am afraid I will fall. At that time, the head of the bed was not locked and could easily move. The mattress was overhanging the bed frame by half a foot and easily slid around on the bed frame. The cushion in R69's wheelchair slid very easily across the seat. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-05-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Findings Based on observation, interview and record review the facility failed to properly store, change and label respiratory equipment for three of three residents (R44, R52 and R7) reviewed for respiratory care on the total sample list of 39. Findings include: 1) On 5/8/23 at 10:31 AM and on 5/9/23 at 11:34 AM R44's aerosol generating delivery system (mask and tubing) was lying on R44's night stand in room on top of the nebulizer machine. R44's aerosol generating delivery system (mask and tubing) was not stored in a bag. R44's physician orders documents, change nebulizer equipment and tubing weekly and place in new bag with name and date, start date: 3/5/21. On 5/10/23 at 10:50 AM V2 Director of Nursing stated, nebulizer equipment (mask and tubing) should be stored in a bag when not in use. The facility's policy, with a revision date of February 2021, titled Administering Medications Through a Small Volume Nebulizer documents, Steps in procedure: 29- When equipment is completely dry, store in a plastic bag with the residents name. 2.) On 5/08/23 at 2:14 PM, R7's CPAP (Continuous…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-05-11 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess for appropriate use of an antibiotic for one resident (R50) reviewed for antibiotic stewardship in the sample list of 39. Findings include: R50's May 2023 Order Summary documents an order dated 7/9/21 to administer Azithromycin (antibiotic) 250 milligrams by mouth three times weekly on Monday, Wednesday, and Friday for diagnosis of Chronic Obstructive Pulmonary Disease (COPD). R50's Care Plan revised 9/21/22 documents in the problem category that R50 receives a prophylactic antibiotic for COPD and in the interventions it lists that R50 receives the prophylactic antibiotic to prevent Urinary Tract Infections (UTIs). R50's Hospital Discharge summary dated [DATE] documents R50 receives Azithromycin three times weekly to prevent bronchitis. There is no documentation that the use of this antibiotic was assessed or re-evaluated for appropriate use. On 05/09/23 at 2:59 PM V3 Infection Preventionist stated the facility uses McGreer's criteria (infection…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$182,948 in federal fines across 3 penalties. 1 Medicare payment denial on record.
- $14,505 — penalty dated 2025-05-05
- $12,425 — penalty dated 2025-02-10
- $156,018 — penalty dated 2024-04-09
- Medicare payment denial — starting 2025-05-23 for 39 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
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PIATT CO. | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 11/30/1973 |
| PORTER, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; ADP OF THE SNF | — | since 10/26/2017 |
| BERKEY, STEPHANIE | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2019 |
| MANINT, JAMES | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2022 |
| TUCKER, HILLARY | Individual | W-2 MANAGING EMPLOYEE; ADP OF THE SNF | — | since 08/01/2012 |
| HEALTH TECHNOLOGIES, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/19/2024 |
| SAPP, CAROL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/19/2024 |
CMS files one row per role, so the 18 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145883. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-18, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.