La Bella of Morrison
500 North Jackson Street, Morrison, IL 61270 · For profit - Limited Liability company · 74 certified beds · (815) 772-7288 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 5 actual-harm citations
- a high number of inspection citations overall (46) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $65,860 in federal fines (most recent 2026-02-24)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (100%) runs well above the national median (45%)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 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 | 21.8% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 11.3% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.2% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 18.2% | 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 | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 21.8% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 25.2% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.8% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 35.3% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 45.1% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.80 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.15 | 2.22 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
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 28% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
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 74 beds and averages 36.9 residents a day — about 50% occupied, or roughly 37 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.91 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.83 hrs/resident/day on weekends vs 3.13 on weekdays — 10% thinner on weekends. RN hours go from 0.65 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 100% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
46 citations, most serious first. The 15 most serious are shown; the remaining 31 are one tap away and print in full.
- Actual harm · Gcited before2026-02-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to safely transfer residents and in a manner to prevent resident falls and injuries for 2 of 5 residents (R1, R3) reviewed for resident safety and supervision in the sample of 7. This failure resulted in R1 sustaining a large leg skin laceration, during a transfer, that required emergent transport to a local hospital for suture repair. The findings include:1.R1's progress notes and hospital records dated 1/23/26 showed R1 sustained a laceration to her left lower leg while being transferred into bed by facility staff. R1 was emergently transported via ambulance to a local hospital for an evaluation of her laceration. R1's leg laceration was repaired with nine (9) sutures. R1 was discharged back to the facility on antibiotics for the laceration and with orders to follow up with the hospital's wound care team.R1's admission physical therapy evaluation dated 1/8/26 showed, Per consultation, patient demonstrated fear of falling as evidenced from patient getting anxious and unable to stand with 1 person assist despite max assistance…
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 · G2025-11-25 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was free of significant medication errors for 1 of 3 residents (R1) reviewed for medication administration in the sample of 7. This failure resulted in R1 requiring 1:1 supervision related to increased restlessness and agitation and resulted in R1 not receiving prescribed antibiotics and being readmitted to the hospital with pneumonia. The findings include: R1's face sheet showed he was admitted to the facility 10/16/25 with diagnoses to include pneumonia due to other gram-negative bacteria, generalized anxiety disorder, malignant neoplasm of prostate, Alzheimer's Disease, and heart failure. R1's facility assessment dated [DATE] showed he had severe cognitive impairment and was dependent upon staff for all cares. R1's October 2025 Physician Order Sheet showed he was admitted with orders for buspirone, alprazolam, Cefdinir, Doxycycline, and furosemide. R1's Care Plan initiated 10/17/25 showed, [R1] has an eye 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.
- Actual harm · Gcited before2025-03-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure interventions were placed when a pressure injury was identified and failed to ensure treatments and pressure reducing interventions were in place for 2 of 3 residents (R33, R21) reviewed for pressure in the sample of 12. This failure resulted in R33 sustaining a stage 3 pressure injury to her coccyx. The findings include: 1. On 3/3/25 at 10:15 AM, R33 was in bed sleeping. R33's air mattress was deflated, and R33 was laying on the bed frame. The air mattress controller said standby. Heel protection boots were observed in R33's wheelchair in the room. At 10:19 AM, V3 Certified Nursing Assistant came into the room and said the air mattress controller was not supposed to say standby. V3 tried to un-plug and re-plug the unit and the mattress did not inflate. V3 looked at the control unit again and discovered the unit was turned off. V3 turned on the unit, and the mattress inflated. V3 said the mattress needs to be turned on in order to relieve pressure and R33 is supposed to have the heel protection boots 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 · Gcited before2024-01-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to safely transfer a resident for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a left leg laceration requiring 29 sutures. The findings include: The facility's Reported Incident Final dated 12/29/23 shows on 12/27/23, R1 sustained a skin tear to left lower extremity. Per staff interviews on file, it was noted resident was being assisted by 2 Certified Nursing Assistants (CNA) from wheelchair to bed using a mechanical lift. During the transfer resident was noted to bump leg on wheelchair. On 1/3/24 at 9:15 AM, R1 was sitting up in a reclining wheelchair in her room. R1 had padded protection sleeves on both arms and lower legs. V4 CNA rolled the padded sleeve down on R1's left lower leg. R1 had a gauze bandage covering her left lower leg. R1 stated I had 29 stitches. It hurts still. I can tell there is something there. V4 said she and V5 CNA were transferring R1 from her bed to the wheelchair and they bumped R1's leg on the wheelchair. V4 said R1 had 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.
- Actual harm · Gcited before2023-05-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assess and monitor a resident (R7) with a history of pneumonia showing a change in condition. This failure resulted in R7 being admitted to the hospital in poor condition. The facility also failed to correctly apply elastic bandages to a resident (R29) with lower extremity edema. This applies to two of two residents (R7 and R29) in the sample of 12 reviewed for quality of care. The findings include: 1. The Physician Order Sheet (POS) for R7 shows diagnosis to include anemia, coronary artery disease and chronic obstructive pulmonary disease. The POS shows orders for oxygen at 2-4 liters via a nasal cannula as needed to keep the oxygen saturations above 90%. The facility assessment dated [DATE] shows R7 to be cognitively intact. On 5/23/23 at 9:21 AM, R7 was observed being taken from the bathroom by staff and placed in her wheelchair. R7 immediately fell asleep, and her breathing sounded congested. R7 would wake up when her name was said but…
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 before2026-05-27 · 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 follow their policy for a safe community pass for 1 of 3 residents (R1) reviewed for safety in the sample of 4. The findings include:On 5/27/26 at 11:05 AM, R1 was sitting outside in his wheelchair. R1 said he recently went out on pass with his girlfriend to his girlfriend's house. R1 said he fell asleep watching a movie and it got late so he stayed the night there and came back to the facility in the morning the next day. R1 said he signed himself out of the facility. On 5/27/26 at 11:20 AM, V7 (Licensed Practical Nurse) said she worked on the day R1 went out on pass. V7 said R1 had asked to go out on pass and V7 asked V1 (Administrator) if R1 was allowed to go out. V7 said V1 said R1 had a high enough cognition score that he could go, but normally you are supposed to call the doctor and get an order. V7 said R1 is alert and oriented times three, is able to transfer himself and has no safety concerns that she was aware of. On 5/27/26 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-05 · 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 ensure residents were treated in a dignified manner. This applies to 3 of 13 residents (R4, R6 & R12) reviewed for dignity in the sample of 15. The findings include: On 5/4/26 at 9:03 AM, R6 stated, V10 former agency Certified Nursing Assistant (CNA) just showed up going into rooms asking if we wanted to go to the bar and get drunk. I told him no. I don't care for that goofball. I don't give a shit about him. On 5/4/26 at 9:12 AM, R4 stated, V10 former agency CNA was her CNA. He would give her cares but never say much to her. All of the sudden she found out that he was terminated from the facility and he came in acting like her best friend. He came in her room and tried to hug her. A nurse (V11 Licensed Practical Nurse (LPN)) was in the hallway telling him, he shouldn't be there and to leave. She stated, she was in shock and didn't know what was going on. On 5/4/26 at 11:36 AM, R12 stated, V10 former agency CNA came in his room asking if I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-05 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was free from physical abuse for 1 of 4 residents (R4) reviewed for abuse in the sample of 15.The findings include:A health status note dated 2/26/26 showed R1 wandered into another resident's (R4) room and tried to take a box of Kleenex. R1 and R4 held onto the box of Kleenex and tugged back and forth. The note showed, Resident (R1) then hit other resident (R4).R4's resident assessment dated [DATE] showed R4 was cognitively intact.R1's current care plan showed R1 was severely cognitively impaired due to her diagnosis of dementia. The plan showed R1 was ambulatory and wandered throughout the facility. The plan showed, Resident wandering and rearranging another resident's room. Resident likes to touch, hug, or kiss others. Resident has a history of being physically aggressive. On 5/4/26 at 8:46 AM, R4 stated R1 goes into everyone's room and takes things. This happens every day. One time she came in here and tried to take my things. I am…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-05 · 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 report an allegation of physical abuse to the facility administrator and other officials, including the State IDPH for 1 of 4 residents (R4) reviewed for abuse in the sample of 15.The findings include:A health status note dated 2/26/26 showed R1 wandered into another resident's (R4) room and tried to take a box of Kleenex. R1 and R4 held onto the box of Kleenex and tugged back and forth. The note showed, Resident (R1) then hit other resident (R4).On 5/4/26 at 8:46 AM, R4 stated R1 goes into everyone's room and takes things. This happens every day. One time she came in here and tried to take my things. I am helpless and can't get out of bed, so I started yelling at her and yelling for help (from staff). R4 stated R1 told R4 I will show you and then R1 punched R4 in the arm. R4 stated, (R1) was mad. She punched my right arm. It wasn't a slap; it was a punch. On 5/4/26 at 12:10 PM, V8 Licensed Practical Nurse (LPN) stated she immediately reported the physical altercation on 2/26/26, between R1 and R4 to V1 Administrator as 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 · D2026-05-05 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to investigate an allegation of physical abuse for 1 of 4 residents (R3) reviewed for abuse in the sample of 15.The findings include:A health status note dated 2/26/26 showed R1 wandered into another resident's (R4) room and tried to take a box of Kleenex. R1 and R4 held onto the box of Kleenex and tugged back and forth. The note showed, Resident (R1) then hit other resident (R4).On 5/4/26 at 8:46 AM, R4 stated R1 goes into everyone's room and takes things. This happens every day. One time she came in here and tried to take my things. I am helpless and can't get out of bed, so I started yelling at her and yelling for help (from staff). R4 stated R1 told R4 I will show you and then R1 punched R4 in the arm. R4 stated, (R1) was mad. She punched my right arm. It wasn't a slap; it was a punch. On 5/4/26 at 12:10 PM, V8 Licensed Practical Nurse (LPN) stated she immediately reported the physical altercation on 2/26/26, between R1 and R4 to V1 Administrator as V1 was the facility's abuse coordinator.On 5/4/26 at 11:55 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 before2026-05-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure prescribed treatments were done for a resident with a surgical wound. This applies to 1 of 3 residents (R6) reviewed for wound care in the sample of 15. The findings include:R6's face sheet lists his diagnoses to include: absence of left foot, absence of right leg below the knee, severe protein-calorie malnutrition and chronic systolic congestive heart failure. On 5/5/26 at 10:15 AM, V4 Registered Nurse (RN) was changing R6's dressing to his right stump surgical dehiscence. R6 had a small pinpoint open area on the incision where he had a below the knee amputation. She cleaned the wound and was going to apply xeroform (petroleum based gauze) to his wound and cover with a dressing. R6 told her, No that is not the right dressing. She asked, what do you mean? Your orders say xeroform and a dressing. R6 stated, no they changed that order and have been using the white stuff (collagen) and then a dressing. He continued to explain 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 before2026-05-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to ensure a resident with a pressure injury received the prescribed treatment. This applies to 1 of 3 residents (R12) reviewed for wound care/pressure ulcer in the sample of 15. The findings include:R12's face sheet lists his diagnoses to include: diabetes mellitus, type 2, heart failure, chronic kidney disease, pressure ulcer of right buttock, stage 3, major depressive disorder, peripheral vascular disease, atrial fibrillation, coronary artery disease and hypertension. On 5/5/26 at 1:46 PM, V4 Registered Nurse (RN) was changing R12's dressings. He had an open pressure ulcer about the size of a dime on his right buttock. She pulled the dressing off and there was a white piece of collagen and a dressing over it. She stated, that wasn't his dressing and wasn't sure why that was on there. The current order was for hydrocolloid paste and to leave open to air. She stated, because the wound looked like it could benefit from being covered she would call and get different orders. R12's treatment administration record 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 · Dcited before2026-05-05 · 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 observation, interview and record review the facility failed to ensure staff did not provide a THC vape pen to a resident for use. This applies to 1 of 15 residents (R6) reviewed for safety in the sample of 15. The findings include:On 5/5/26 at 1:20 PM, V13 laundry/housekeeping stated, he saw V10 former agency Certified Nursing Assistant (CNA) outside with the residents while they were smoking. He saw V10 give R6 a THC (marijuana) vape pen to use. R6 took the pen and used it. He asked other staff members if they knew about it and other staff members stated, he has done it before. He did not report that information to V1 Administrator. He confirmed he knew it was THC by the style of vape pen and they look different than nicotine vape pens. On 5/5/26 at 1:35 PM, V12 Registered Nurse (RN) stated, she had heard that staff were giving THC pens to residents. V13 laundry/housekeeping told her that he saw him give the THC pen to R6. She told him, he needed to report that to V1 Administrator. She has had a few…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-05 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to manage a resident's pain by not administering analgesic pain medications as prescribed for 1 of 3 residents (R8) reviewed for pain management in the sample of 15.The findings include:A physician order for R8 dated 4/20/26 showed, Hydrocodone-Acetaminophen (Norco/narcotic pain medication) 5/325 milligrams, give 1 tablet every 6 hours as needed for pain.R8's provider note dated 4/21/26 showed resident has continued complaints of right foot/heal pain, which she states has already had imaging of and is awaiting insurance approval for CT scan. She currently has orders for Hydrocodone-acetaminophen for pain as needed.On 5/4/26 at 10:32 AM, R8 was in bed. R8 stated she didn't feel well because she had not received any Norco since last Thursday (4/30/26). R8 stated, I have rheumatoid arthritis, fibromyalgia, and pain in my foot. I usually take 2 Norco a day for my pain. I haven't gotten it (Norco) since last week because they say they ordered my medication, but it hasn't been delivered yet. R8 rated her current pain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-05 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 prevent a resident, with a diagnosis of dementia, from wandering into other resident rooms for 1 of 1 residents (R1) reviewed for dementia care in the sample of 15. The findings include:R1's current care plan showed R1 was severely cognitively impaired due to her diagnosis of dementia. The plan showed R1 was ambulatory and wandered throughout the facility. The plan showed, Resident wandering and rearranging another resident's room. Resident likes to touch, hug, or kiss others. Resident has a history of being physically aggressive. The plan showed staff were to closely monitor and intervene when needed to prevent R1 from wandering into other resident rooms by offering R1 structured activities and pleasant diversions. R1's health status notes dated 2/22/26 and 2/26/26 showed R1 was found in a resident's room (R4), attempting to take belongings from R4. On 2/22/26, R1 and R4 got into a verbal argument due to R1 being in R4's room. R1 attempted to hit R4 but was unsuccessful as staff intervened in time. On 2/26/26,…
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.
Show the remaining 31 citations
- Potential for harm · Dcited before2026-05-01 · 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 — an excerpt from the official record, may be distressing
Based on observation and interview the facility failed to have a working heating/air conditioning unit in a resident room. This applies to 2 of 4 residents (R4 and R7) reviewed for clean, comfortable and homelike conditions in the sample of 7. The findings include: On 5/1/26 at 9:30AM, R4 stated, I have had no AC (Air conditioning) or heat in my room for the last 2 weeks. The unit does not work. On 5/1/26 at 10:30AM Surveyor observed the AC/ Heat unit in R4 and R7's room. The unit was a wall unit, plugged into the wall. Surveyor pushed the power button, but the unit would not turn on. On 5/1/26 the internet showed it was about 55 degrees outside, however on April 21, 22, and 23 the temperature outside was in the low to mid 80's. R4 had 2 fans on an overbed table both on and pointed at her bed. On 5/1/26 at 12:00PM V3 (Maintenance Director from a sister facility) stated, I didn't know it was not working. V3 then walked with Surveyor to R4 and R7's room to look at the unit. V3 was unable to turn the unit on. V3 pushed two buttons on the unit's electrical cord plug several times 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 · Dcited before2026-05-01 · 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
Based on observation, interview and record review the facility failed to ensure a resident who is dependent on staff received incontinence care and showers. This applies to 1 of 3 residents (R1) reviewed for activities of daily living (ADL) in the sample of 7. The findings include: R1's face sheet shows she has diagnoses including COPD, lymphedema, type 2 diabetes, peripheral vascular disease, chronic kidney disease, major depressive disorder, morbid obesity, and generalized anxiety. On 5/1/26 at 9:14 AM, V7 and V8 (Certified Nursing Assistant's) were in R1's room providing incontinence care. A strong smell of urine was permeating from her room. On 5/1/26 at 9:17 AM, R1 was laying in bariatric bed. R1 said she was soaked with urine and the last time she was changed was at 10:30 PM last night. R1 said she prefers not be woken up when she is sleeping during the night, but would like staff to change her in the early morning. R1 said she's been up since 5:00 AM, and staff did not change me until now. R1 said her shower days are on Wednesday and Saturdays. She did not receive a shower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-27 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have a call system in place allowing residents to call for assistance for 3 of 3 residents (R1, R2, and R3) reviewed for call system in the sample of 3.The findings include:1. R1's admission Record printed on 4/27/26 showed R1 admitted to the facility on [DATE]. The same document showed R1 was [AGE] years old.On 4/27/26 at 11:43 AM, R1 was in her room. R1's call light by her bed and in the bathroom were not working. R1 confirmed her call lights were not working. R1 said staff provided her with a drum to use when she needed help. R1 said she was not able to use the drum. R1 attempted to use the drum. No audible drum noise could be heard at R1's door. R1 said when she needed help, she had to yell or wait for staff to check on her.On 4/27/26 at 11:43 AM, V3 (R1's Daughter in-law) said R1 was not physically capable of making a loud sound with the drum and the call light system had not worked since R1 was admitted to the facility on [DATE].R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an initial assessment was completed of wounds upon admission and failed to ensure weekly wound assessments were completed for 2 of 3 residents (R3, R1) reviewed for wounds in the sample of 7.The findings include:1. R3's face sheet showed he was admitted to the facility 3/12/26 with diagnoses to include chronic obstructive pulmonary disease, severe calorie malnutrition, gangrene, chronic respiratory failure, and retention of urine. R3's record showed he was admitted on hospice services. R3's facility assessment dated [DATE] showed he has moderate cognitive impairment and requires extensive assistance for all cares.On 4/14/26 the facility provided wound assessments for R3's skin conditions including a 3/12/26 Skin check which showed, . Foot evaluation completed. Skin Issues: . Location Right heel. This assessment showed no measurements and did not include R3's wound to his left foot. The only other assessment found in R3's record 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 · D2026-03-19 · 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 interview and record review the facility failed to notify the ombudsman of a discharged resident for 1 of 3 residents (R1) reviewed for discharge in the sample of 3.The findings include:R1s admission record shows she was admitted to the facility on [DATE], and she discharged on 3/11/2026 to home.R1s resident assessment and care screening of 3/3/26 documents her as cognitively intact. She was independent with supervision for her self-care needs, and independent with mobility.On 3/19/26 at 9:40 AM, V4 (Ombudsman) said R1 was issued an involuntary discharge due to non-payment. She was working with R1 on the case, including filing an appeal and setting up a hearing for April. V4 said she obtained representation for R1 regarding the hearing and notified the facility. She said a message had been left for her by V3 (Adult Protective Services-APS) care worker R1 had discharged from the facility. She said R1 had been discharged on 3/11/26, and to this day the facility still had not sent any notification 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 before2026-02-24 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to honor and implement a resident's DNR (do not resuscitate) status as indicated per the resident's POLST form (Physician Orders for Life-Sustaining Treatment form) for 1 of 3 residents (R5) reviewed for advance directives in the sample of 7.The findings include:R5's admission record showed R5 was admitted to the facility, from a local hospital, on 2/10/26. R5's hospital discharge orders dated 2/10/26 showed R5 was a DNR. R5's admission care plan dated 2/10/26 showed R5 was cognitively impaired. R5's care plan showed no documentation related to R5's advanced directives. R5's healthcare Power of Attorney (POA) form dated 12/8/25 showed V15 was R5's POA. A POLST form dated 2/20/26 showed R5 was a DNR.On 2/24/26 at 10:23 AM, V15 (R5's POA) stated, (R5) is supposed to be a DNR. They (facility) have a signed POLST form showing this, but they said they couldn't honor the form until their (the facility's) medical director signs off on the DNR. That doesn't make sense.A physician order dated 2/12/26 showed R5 was a Full Code. 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 · Dcited before2026-02-24 · 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 incontinence care to residents dependent on staff for cares for 2 of 4 residents (R1, R2) reviewed for activities of daily living (ADLs) in the sample of 7. The findings include:1.R1's resident assessment dated [DATE] showed R1 was cognitively impaired and was dependent on staff for toileting and incontinence care. On 2/23/26 at 10:24 AM, V6 (R1's private caregiver) stated she visits R1 daily in the facility. V6 stated, They don't toilet (R1) or change her brief unless I ask them too. She will sit in the same brief for hours.On 2/23/26 at 8:28 AM, R1 was dressed and seated in the dining room eating breakfast. V4 Certified Nursing Assistant (CNA) stated she had last changed R1's incontinence brief around 7:00 AM that morning, prior to getting her dressed for the day.On 2/23/26 at 9:13 AM, R1 was moved from the dining room to the activity room by facility staff. On 2/23/26 at 9:45 AM, R1 remained seated in her wheelchair in 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 before2026-02-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to provide daily wound treatments to a resident's leg laceration for 1 of 3 residents (R1) reviewed for wounds in the sample of 7.The findings include:R1's progress notes and hospital records dated 1/23/26 showed R1 sustained a laceration to her left lower leg while being transferred into bed by facility staff. R1 was emergently transported via ambulance to a local hospital for an evaluation of her laceration. R1's leg laceration was repaired with nine (9) sutures. R1 was discharged back to the facility with orders for facility staff to provide daily wound treatments and dressing changes to R1's laceration.On 2/23/26 at 10:24 AM, R1 was seated next to V6 (R1's private caregiver) in the activity room. A gauze dressing was noted around R1's left lower leg. No date was noted on the dressing. V6 stated, Every day, I have to ask them (facility staff) to change her leg dressing. There were two days, on February 11 and 12th, they didn't change her dressing at all.On 2/23/26 at 2:00 PM, this surveyor reviewed R1's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-02-24 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to administer resident medications at the correct time and as per physician order. The facility failed to monitor a resident's blood glucose (sugar) level at the correct time and as per physician order. These failures apply to 1 of 3 residents (R5) reviewed for medication administration in the sample of 7.The findings include:R5's admission record showed R5 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus.On 2/24/26 at 10:23 AM, V15 (R5's Power of Attorney/POA) stated the facility had not been checking R5's blood glucose levels like they were supposed to. V15 also stated the facility had been giving R5 his medications late. R5's February 2026 Medication Administration Record showed the following orders for R5;Accu-checks (blood glucose monitoring) to be done before meals and at bedtime. R5's accu-checks to be done daily at 6:30 AM, 11:30 AM, 4:30 AM, 9:00 PM.Humulin R (regular insulin); inject 3 units subcutaneously…
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 · D2025-11-25 · tag F0713 — isolatedProvide or arrange emergency care by a doctor 24 hours a day.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a physician was overseeing the facility. This applies to all residents residing in the facility.The findings include:The facility provided a resident roster dated 11/22/25 which showed 36 residents residing at the facility.On 11/22/25 at 11:15 AM, this surveyor observed a note posted at the nursing station that showed, [The Medical Director] is on vacation 11/20 - 12/1 . DO NOT CALL OR TEXT - IF YOU NEED ASSISTANCE CALL THE OFFICE at [PHONE NUMBER]. A note was handwritten under the posting that showed, no one answers at this number, on any of the extensions and there is no option to leave a message with anyone but billing. [Administrator] and DON (Director of Nursing) are aware - unsure of the situation at this time. If any issues just send to ED (Emergency Department). Also, won't have any scripts (prescriptions) available. This posting showed it was faxed to the facility by the Medical Director's office. On 11/22/25 at 11:15 AM,…
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 before2025-11-25 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure nurses had access to the convenience medications and failed to ensure medications were available from the pharmacy for 2 of 3 residents (R1 and R3) reviewed for pharmacy services in the sample of 7.The findings include:1. R1's face sheet showed he was admitted to the facility 10/16/25 with diagnoses to include pneumonia due to other gram-negative bacteria, generalized anxiety disorder, malignant neoplasm of prostate, Alzheimer's Disease, and heart failure. R1's facility assessment dated [DATE] showed he had severe cognitive impairment and was dependent upon staff for all cares. R1's October 2025 Physician Order Sheet showed he was admitted with orders for buspirone, alprazolam, Cefdinir, Donepezil HCL, Doxycycline, furosemide, memantine, spironolactone, and tamsulosin. R1's October 2025 eMAR (electronic Medication Administration Record) showed the only medication he was administered for the first 48 hours after his admission was his melatonin. 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 · D2025-09-16 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a discharge planning process and include this process in the resident's electronic medical record including the comprehensive plan of care for 2 of 3 residents (R2, R3) reviewed for discharge planning in the sample of 5.The findings include:1. On 9/16/25 R2 stated he was ready to go home and has been for a while. R2 stated he was supposed to be discharged on Monday, that did not happen. R2 stated now someone stated it would probably be on Thursday. R2 stated he was told that they were waiting for the doctor's signature before he can leave. R2 stated he did not know anything about his discharge plans other than he is going to be discharged . On 9/16/25 at 12:11 PM, V9 Social Services stated R2 was finished with therapy and waiting for the doctor's order for discharge. V9 stated the facility just had a new medical director start and they are waiting on the order from him. V9 stated the current plan is for R2 to discharge home 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 · Fcited before2025-03-05 · tag F0584 — failed to keep a safe, clean, comfortable home — widespreadHonor 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 — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure the resident shower room was clean, comfortable, and homelike and failed to ensure hot water was available in resident bathrooms. This applies to all 35 residents residing at the facility. The findings include: The facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 3/3/25 shows there is a resident census of 35. 1. On 3/4/25 at 9:31 AM, in the resident shower room V3 Certified Nursing Assistant pointed out the drain in the floor. The drain was uncovered with a hole exposed (the size of a softball) in the center of the shower room floor, under the shower head. V3 stated this morning I gave a shower and the wheel of the wheelchair got stuck in the drain. Look at this room! The tiles are missing and some tiles tape to hold them up. On 3/4/25 at 1:19 PM, R8 stated I've been here for 9 years and every year I complain about shower room. It was really pretty bad. This is a little better than before. It is still bad though, the walls have holes, tiles are missing, but it is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — widespreadEnsure 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 ensure water temperatures were monitored and maintained in resident care areas, and failed to ensure a resident's call light was within reach which applies to all 35 residents in the facility. The findings include: 1. The CMS-671 document dated 3/3/25 showed the facility census was 35 residents. On 3/3/25 at 1:55 PM, the resident bathroom for rooms [ROOM NUMBERS] (shared bathroom) hot water temperature was 121.5 degrees Fahrenheit (F). An electronic calibrated thermometer was used for this reading. On 3/3/25 at 2:05 PM, the facility's hot water heater thermometer read 125 degrees Fahrenheit. The mixing valve thermometer read 120 degrees Fahrenheit. On 3/3/25 at 2:15 PM, V9 took rooms [ROOM NUMBERS]'s hot water temperature. The reading was 119.4 degrees (F). V9 stated the water temperature is high. V9 stated he was getting higher temperatures than that and turned down the hot water heater to 125 degrees about a week ago. V9 stated he called 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.
- Potential for harm · D2025-03-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess, care plan and obtain physician orders for 2 of 12 residents (R27 and R22) to self-administer medications in the sample of 12 residents reviewed for medication safety. The findings include: 1. On 3/3/25 at 10:22 AM, R27 showed surveyor a box of lidocaine patches (medicated pain patches) in her bedside stand. R27 said she uses them on her right hip for pain. R27 also showed surveyor her inhaler and said the facility gave her both medications to use. R27's admission Record dated 3/5/25 shows she is a [AGE] year old resident admitted to the facility on [DATE]. R27's Order Summary Report dated 3/3/25 shows an order for Aspercreme Lidocaine External Patch 4% (Lidocaine) apply to lower back topically one time a day for pain, on in AM and off at bedtime. May keep in room and remove per schedule, but it does not show an order for R27 to self-administer any of her medications. On 3/3/25 at 10:19 AM, V2, Director of Nursing (DON), said there…
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 · D2025-03-05 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident was assessed for the use of a restraint which applies to 1 of 1 resident (R20) reviewed for restraints in a sample of 12. The findings include: R20's admission Record printed on 3/5/25 showed R20 as a [AGE] year old cognitively impaired female resident with diagnoses which includes autistic disorder and Downs syndrome. On 3/3/25 at 8:45 AM, R20 was sitting in a wheelchair with a restraint vest on near the nurse's station. The vest had a strap with a clip on each corner of the vest. One strap went on either side of R20's head and the other 2 straps went under R20's armpits to fasten to the back of the chair. On 3/4/25 at 12:35 PM, R20 was sitting in a recliner in a common area near the nurse's station. R20 started having behaviors, which included pushing over a bedside table, and lashing out towards staff. Staff escorted R20 to her room. At 1:40 PM, V3 Certified Nursing Assistant (CNA) brought R20 out of her room in her…
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 · D2025-03-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's comprehensive careplan included interventions for a chest harness which applies to 1 of 12 residents (R20) reviewed for careplans in a sample of 12. The findings include: During the survey, R20 was observed wearing a restraint harness while in her wheelchair. R20 was utilizing the harness on 3/3/25 at 8:45 AM, 3/4/25 at 1:40 PM and 2:55 PM. R20's Medical record showed no assessment was completed since R20's admission on [DATE]. On 3/4/25 at 10:35 AM, V2 Director of Nursing stated a restraint should be in a resident's care plan. R20's current care plan showed no focus area or interventions in place for a restraint.
- Potential for harm · Dcited before2025-03-05 · 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 ensure a resident's nails were trimmed for a resident with a hand contracture which applies to 1 of 12 residents (R15) reviewed for activities of daily living in a sample of 12. The findings include: R15's admission Record printed on 3/5/25 showed R15 to be a [AGE] year old male resident, originally admitted to the facility on [DATE] with diagnoses which include a contracture to the left hand and muscle weakness. On 3/3/25 at 10:10 AM, R15 was in his room watching television. R15's nails were noted to be approximately 1/4 inch long. R15 opened his hand with other hand. R15's left palm had indentations from his fingernails pressing into his palm. On 3/4/25 at 9:20 AM, R15 still had long nails with left hand closed. On 3/4/25 at 1:30 PM, V11 Certified Nursing Assistant assisted R15 with opening his hand. R15 had indentation marks from his fingernails in his palm. V11 stated R15's nails were too long (approximately 1/4 inch) and needed to be…
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 before2025-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure elastic bandages (tubi grips) were applied for a resident with a history of lower extremity edema for 1 of 12 residents (R5) reviewed for quality of care in the sample of 12. The findings include: On 3/3/25 at 10:35 AM, R5 was up in her wheelchair propelling herself in the activity room. R5 had socks on to her ankles and her skin was visible above the sock (no elastic wraps were in place). On 3/3/25 at 1:49 PM, R5 was up in her wheelchair in the activity room with no visible elastic wraps on her legs. On 3/4/25 at 1:22 PM, R5 was sitting up in her wheelchair in the activity room with her feet on the floor. V3 Certified Nursing Assistant (CNA) lifted R5's pant leg and R5 only had on socks that came up to her ankles. There were no elastic bandages observed. V3 said she is supposed to have wraps on her legs. On 3/4/25 at 1:24 PM, V4 Licensed Practical Nurse said R5 is supposed to wear elastic bandages during the day for circulation and to prevent edema. V4 said R5 has had the order for some time and R5…
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 · D2025-03-05 · 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 — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to ensure psychotropic medication orders contained a duration for 1 of 6 residents (R33) reviewed for psychotropic medications in the sample of 12. The findings include: On 3/5/25 at 10:30 AM, V1 Administrator said all psychotropic as needed medications need to have a stop date. R33's Physician Orders contained an order dated 1/13/25 for Lorazepam Oral Concentrate 2 MG (milligrams)/ML (milliliter) Give 0.25 ml by mouth every 2 hours as needed for anxiety related to generalized anxiety disorder. The order did not contain a stop date (duration). The facility's Use of Psychotropic Medications Policy dated 3/2025 shows PRN [as needed] orders for psychotropic medication, excluding antipsychotics, shall be limited to no more than 14 days.
- Potential for harm · D2025-03-05 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 residents were assessed and offered pneumococcal immunizations upon admission for 2 of 5 residents reviewed for vaccinations in the sample of 12. The findings include: R15's admission Record dated 3/5/25 shows he was admitted to the facility on [DATE]. R15's Immunizations list provided on 3/5/25 shows no historical or current record of R15 having had or being offered a pneumococcal immunization. R21's admission Record dated 3/5/25 shows she was admitted to the facility on [DATE]. R21's Immunizations list provided on 3/5/25 shows no historical or current record of R21 having had or being offered a pneumococcal immunization. On 3/5/25 at 10:26 AM, V2, Director of Nursing/Infection Prevention Nurse, said when a resident is admitted , the admitting nurse is supposed to screen the residents for their vaccination status and administer them. V2 said the previous DON, dropped the ball on vaccines. The facility's Pneumococcal Vaccine Policy (reviewed…
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 · F2024-04-11 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure the facility water system was tested for Legionella and failed to ensure water was not sedentary in an unoccupied area of the facility. This failure had the potential to affect all 28 facility residents. The findings include: The facility's 4/9/24 application for Medicare and Medicaid form showed there were 28 residents in the facility. On 04/10/24 at 11:02 AM, V4 Maintenance said weekly he flushes toilets and runs water for 2-3 minutes on anything that has a faucet on the south hall. V4 said he was unsure if a water system assessment had been done to identify potential problem areas that may be conducive to water borne pathogen growth. V4 said he did not know the last time water testing for Legionella was done if ever. Testing results and a policy were requested. V4 said V5 Business Office Manager (BOM) was his supervisor. At 11:21 AM, V5 said she thought the facility was last tested for Legionella in 2019. V5 said she would check with the city since they do some testing. This surveyor requested 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.
- Potential for harm · F2024-04-11 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to have a certified Infection Preventionist. This failure could affect all 28 facility residents. The findings include: The facility's 4/9/24 application for Medicare and Medicaid form showed there were 28 residents in the facility. On 04/10/24 at 10:05 AM, V2 Director of Nursing (DON) said she has been at the facility since January 29, 2024. V2 said she is the facility's Infection Preventionist (IP). V2 said she did not have IP certification. On 04/11/24 at 08:34 AM, V1 Administrator said I am aware it is required to have a certified infection preventionist in the facility. V1 said V2 is trying to get through the course but is not currently certified. It's important to have a certified IP. We need to make sure the residents are safe and protected from infection. The facility's 3/3/23 Infection Preventionist Job Description showed qualifications: must have completed specialty training in infection prevention and control through accredited continuing education such as Centers for Disease Control and Prevention (CDC) or APIC…
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 before2024-04-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident's advanced directives were updated as requested for 1 of 1 resident (R18) reviewed for advanced directives in the sample of 13. The findings include: R18's profile face sheet documents he was admitted to the facility on [DATE]. The Practitioner Order for Life-Sustaining Treatment (POLST) form dated 12/16/21 shows R18 opted to be a full code. The April 2024 POS (Physician order sheet) notes R18 to be a full code. A new POLST form, undated, on the front of R18's chart shows he opted to become a DNAR (Do not attempt resuscitation). The form is signed by R18 and has no witness signature and no signature by the health care practitioner. The facility's 3/21/24 assessment for a significant change documents R18 to be cognitively intact. On 4/11/24 at 9:39 AM, R18 said they did go over all of the options with me, and I signed the paper to not do anything for me. On 4/11/24 at 8:15 AM, V3 RN (Registered Nurse) said R18 was placed on hospice, 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 · Dcited before2024-04-11 · 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 ensure a resident received necessary treatment and services for her amputated leg including following up with her surgeon, obtaining a sleeve for her stump and assisting in the process to prepare and obtain a prosthetic leg for 1 of 1 resident (R26) reviewed for quality of care in the sample of 13. The findings include: On 4/9/24 at 10:45 AM, R26 was sitting in her wheelchair in her room and had a left above the knee leg amputation. R26 stated she has been at the facility for 9 months. R26 stated she came to the facility after a house fire in which she jumped out of a second story window and sustained numerous injuries' including the amputation of her leg. R26 stated she was supposed to have a sleeve for her left leg stump after surgery. R26 stated the facility said they would get her one. It took 4.5 months to get a shrinker and no one measured her for it. R26 stated she has swelling to her left leg/stump. R26 pulled her leggings down to show an elastic type covering to her leg stump that had a lot of extra…
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 before2024-04-11 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure pressure injury interventions were in place as ordered and failed to identify a pressure injury prior to the injury becoming a stage 2 pressure injury for 2 of 5 residents (R5, R4) reviewed for pressure injuries in the sample of 13. The findings include: 1. R5's profile face sheet documents she was admitted to the facility on [DATE]. The facility's annual assessment of 1/10/24 documents R5 to be cognitively intact. The same document shows she is at risk for pressure injuries and had one or more unhealed pressure injuries. The 12/14/23 wound evaluation and management summary report shows an initial evaluation of a stage 2 pressure wound to the sacrum of greater than 4 days in duration. The wound measured 2.9 cm (centimeters) in length, 0.3 cm (width) and 0.2 cm (depth). The nursing progress notes were reviewed and no not show a report or initial identification of any open pressure areas. R5's December 2023 treatment record does not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-04-11 · 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 ensure a catheter had a secure device in place, the drainage bag was kept off the bed, and the catheter tubing was cleaned in a manner to prevent contamination for 1 of 1 resident (R17) reviewed for catheters in the sample of 13. The findings include: On 4/10/24 at 2:23 PM, R17 was laying on her back in bed with her catheter drainage bag attached to the lower bed frame of her bed. R17 did not have a device in place to secure the catheter tubing. V9 CNA (Certified Nursing Assistant) and V10 CNA put on gowns and gloves and went into R17's room to provide catheter care. V9 took a wet washcloth, cleaned R17's groin, and discarded the washcloth. V9 took another wet washcloth, wiped R17's vaginal area and then wiped straight down the catheter tubing. V9 placed the drainage bag on R17's bed when V9 and V10 were repositioning R17 in bed. V9 and V10 stated they were not aware that the catheter drainage bag could not lay on the resident's bed. V9 stated she should have gotten a clean washcloth to wipe down R17's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-05-25 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility failed to provide 8 hours of Registered Nurse (RN) coverage daily. This applies to all 35 residents residing in the facility. The findings include: The facility Resident Census and Conditions report dated 5/23/23, shows the facility census to be 35 residents. On 5/23/23, V3 LPN (Licensed Practical Nurse) said the nurses work 12 hour shifts, and she is the only nurse on duty for the facility, the DON (Director of Nursing) was on vacation. She said there was no RN in the facility at this time. A review of the nursing schedule for May 16- May 31,2023 shows on May 18th, 19th, 22nd, and 23rd, no RN coverage was scheduled. On 5/25/23 at 09:20 AM, V2 LPN/MDS coordinator (Licensed Practical Nurse/Minimum Data Set) said the DON had been on vacation since 5/18/23. V2 said the DON worked the night shift on 5/17/23. V2 said she was aware of the required 8 hours of RN coverage and said the facility does not meet the requirement. On 5/25/23 at 9:30 AM, V1 (Administrator) said the facility had no written policy for staffing, they follow the state…
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 before2023-05-25 · 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 provide dignity for 1 of 1 resident (R34) reviewed for dignity in the sample of 12. The findings include: R34's face sheet documents she was admitted to the facility on [DATE]. The May 2023 POS (Physician Order Sheet) documents multiple diagnoses including dementia. The treatment orders include catheter care twice daily. The quarterly resident assessment of 4/14/23, shows R34 to have moderate cognitive impairment. The same assessment shows R34 requires limited assist of one person for ADL's (Activities of Daily Living). On 5/23/23 at 9:12 AM, R34 was observed sitting in a high back wheelchair at the nurses station. She had a urinary drainage bag hanging on the side of her wheelchair. The bag was not placed in a dignity bag and had yellow urine visible in the bag. On 5/24/23 at 12:00 PM, V7 and V8 CNAs (Certified Nursing Assistants) said the facility does have dignity bags for the urinary drainage bags, but they tear easily. Each said 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 · D2023-05-25 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident tube feeding bag was changed for one of one resident (R5) reviewed for tube feeding in the sample of 12. The findings include: R5's face sheet printed on 5/25/23 showed diagnoses including but not limited to dementia, cognitive communication deficit, and dysphagia (difficulty swallowing). R5's facility assessment dated [DATE] showed moderate cognitive impairment and requires staff assistance with bed mobility, transfers, dressing, toilet use, and hygiene. R5's May physician orders showed an order start dated 5/12/23 for Jevity 1.5 (liquid nutritional formula) 30 milliliters per hour continuous feeding. May hold 3 to 6 hours for discomfort. On 5/23/23 at 10:47 AM, R5 was lying in bed and her feeding tube was running at 30 milliliters per hour. The liquid nutrition was in a bag dated 5/20/23 and the tubing had a tag on it. The tag did not have any documentation on it. At 1:42 PM, R5 was not in her room and the feeding tube…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-03-05 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to post the daily staffing for all 35 residents reviewed for staffing. The findings include: The facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 3/3/25 shows there is a resident census of 35. On 3/3/25-3/5/25 upon entering the facility, there were no staffing postings observed near the front door on the entry table or the bulletin boards. On 3/5/25 at 1:25 PM, V8 Certified Nursing (CNA) Supervisor stated staffing is posted in the staffing binder at the nurse's station. V8 said the binder has the monthly and daily schedules for nursing and CNA. V8 said staffing is not posted near the front door for visitors to see. V8 said she was not aware staffing needed to be visibly posted.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$65,860 in federal fines across 3 penalties.
- $15,935 — penalty dated 2026-02-24
- $38,745 — penalty dated 2025-11-25
- $11,180 — penalty dated 2024-01-03
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 | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $445K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 146084. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-05, 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.