Oakview Nursing & Rehab
1320 West 9th Street, Mount Carmel, IL 62863 · For profit - Limited Liability company · 90 certified beds · (618) 263-4337 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Nov 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $11,660 in federal fines (most recent 2025-01-17)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 fell from 4 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.9% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.4% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 5.6% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 8.1% | 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 | 7.3% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.0% | 14.3% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.8% | 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 | 3.3% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 19.7% | 20.6% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.3% | 21.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 5.6% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 56.2% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.3% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 18.0% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.41 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.32 | 2.22 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
38.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 108 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 45 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 38.2%CMS range 31.5–46.6 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 7.7–15.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 55.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 48.9% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 42.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 4.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.0%CMS range 5.4–12.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 90 beds and averages 63.1 residents a day — about 70% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.09 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 2.06 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 2.91 hrs/resident/day on weekends vs 3.16 on weekdays — 8% thinner on weekends. RN hours go from 0.61 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 38% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · Gcited before2025-01-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an environment free of accident hazards for 1 (R16) of 4 residents reviewed for accidents in the sample of 42. This failure resulted in R16 acquiring a laceration to her left lower leg resulting in 12 sutures being placed. This past noncompliance occurred between 11/27/24 and 11/28/24. The findings include: R16's admission Record documented an admission date of 7/15/2024, and diagnoses including neurocognitive disorder with lewy bodies, weakness, and unspecified diastolic (congestive) heart failure. R16's Minimum Data Set (MDS), dated [DATE], documented under section GG- Mobility that R16 is dependent, which means helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for a chair/bed-to chair transfer. R16's Care Plan documents focus areas of potential impairment to skin integrity, with an initiation date of 7/18/24, and Potential for falls/injury r/t (related to) dx (diagnoses) 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.
- Actual harm · Gcited before2024-11-25 · 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 residents were free from falls with serious injury, transferred safely with a mechanical lift using two staff members, and fall interventions were implemented to prevent falls for 4 of 4 residents (R3, R4, R8, and R9) reviewed for falls in a sample of 42. This failure resulted in R9 falling backwards out of the transport van approximately three feet onto the ground, which resulted in a fracture of her back in two places. Findings Include: 1. R9's admission Record, with a print date of 11/20/24, documents R9 was admitted to the facility on [DATE], with diagnoses that include diabetes, fibromylagia, hypertension, and difficulty in walking. R9's MDS (Minimum Data Set), dated 10/11/24, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R9 is cognitively intact. A facility Initial Report, with an incident date of 11/11/24 for R9, documents, (R9) was transported per facility vehicle to doctors appointment. Upon…
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 · F2026-06-03 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure garbage was removed in a timely manner. This deficient sanitation practice has the potential to affect all 60 residents who reside in the facility.Findings include:On 6/3/26 at 10:04 AM, V6 (Registered Nurse/ RN) said the facility's garbage disposal company did not come to empty the dumpsters for a week and the 2 dumpsters in the parking lot were overflowing with garbage. V6 said during this time, there was an abundance of garbage being left in the facility's soiled utility rooms.On 6/3/26 at 11:47 AM, V5 (Housekeeper) said the weekend prior to Memorial Day, 5/25/26, and a few days after Memorial Day, the facility's dumpsters were overflowing with garbage. V5 said the facility was keeping garbage in the soiled utility rooms until the dumpsters could get emptied. V5 said there was increased odor in the facility during that time.On 6/3/26 at 12:38 PM, V3 (Housekeeping Supervisor) said she was not working 5/23/26- 5/26/26. V3 said when she came back on 5/26/26 the dumpsters in the parking lot were full and overflowing.…
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 · D2026-04-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow the enhanced barrier precautions of wearing a gown and maintaining aseptic technique while performing indwelling catheter care for 1 (R5) of 4 residents reviewed for indwelling catheter care in a sample of 31. Findings included:R5's admission Record documented an admission date of 6/1/2018, with diagnoses including type chronic kidney disease, type 2 diabetes mellites without complications, uninhibited neuropathic bladder, not elsewhere classified, and neuromuscular dysfunction of bladder, unspecified.R5's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 06, showing R5 had severe cognitive impairment. This same document had documented under Section H-H:0100. Appliances: Indwelling catheter (including suprapubic catheter and nephrostomy tube) with yes.R5's Physician Order Sheet (POS) documented on 7/1/2024 an order, (R5) placed on enhanced barrier precautions related to suprapubic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-28 · tag F0729 — widespreadVerify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
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 Certified Nursing Assistant was certified by verifying continuous employment on the Health Care Worker Registry. This has the potential to affect all 80 residents currently residing at the facility. Findings Include: The facility undated Resident Matrix provided to this surveyor on [DATE] documents 80 residents reside at the facility. The untitled and undated staff roster given to this surveyor on [DATE] documents V11 (Certified Nursing Assistant/CNA) was hired by the facility on [DATE]. V11's Health Care Worker Registry Check, dated [DATE], documents under Work Eligibility: Eligible. The registry documents the following statement. In addition to Work Eligitibility, Employers are responsible for checking Training and Work History and Certifications to determine if person is eligible to work in a position that requires certification, such as CNA. This same Health Care Worker Registry Check documents V11's employement was verified on [DATE] 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 · E2025-01-17 · tag F0679 — failed to provide activities — patternProvide activities to meet all resident's needs.
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 provide activities to residents for 4 of 4 (R31, R43, R52, and R129) residents reviewed for activities in a sample of 42. The Findings Include: R31's admission record documents an admission date of 7/16/24, and includes the following diagnoses: muscular dystrophy, cerebral palsy, and depression. R31's quarterly Minimum Date Set (MDS), dated [DATE], documents in Section C a BIMS (Brief Interview of Mental Status) score of 15, indicating R31 is cognitively intact. On 1/16/25 at 9:30 AM, R31 complained there is not enough to do in the facility, especially on the weekends. R31 stated they sometimes get coloring sheets printed off to color on over the weekend, but not every weekend. During the resident council meeting on 1/15/25 at 10:21AM, R31, R43, R52, and R129, who were all alert to person, place, and time, all stated there is not enough to do on the weekend for activities. Review of resident council minutes for 12 months has no documentation 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 · D2025-01-17 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 accurate Minimum Data Set (MDS) coding for 3 (R7, R63, R40) of 5 residents reviewed for MDS assessments in the sample of 42. Findings include: 1. R7's admission Record documented an admission date of 1/12/2022, with diagnoses including unspecified bipolar disorder, major depressive disorder, and paranoid schizophrenia. R7's MDS with an assessment reference date of 10/25/2024, documents under A1500. Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? with a response of No. R7's Care plan, dated 8/9/2024, documented a focus area of potential for communication problems related to diagnoses of dementia, hallucinations, panic disorder, paranoid schizophrenia, delusional disorders, bipolar disorder, depression, anxiety with appropriate interventions. R7's PASRR Level II, dated 4/26/2024,…
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 · D2025-01-17 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R23) of 4 residents reviewed for PASRR Screening in the sample of 42. Findings Include: R23's admission Record documented an admission date of 12/30/2022, with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, dysphasia and an additional diagnosis of bipolar disorder added 8/28/24. R23's Annual Minimum Data Set (MDS) documented an assessment date of 11/18/2024. Under section I: Active Diagnosis: I5900 it documents a Psychiatric/Mood Disorder diagnosis of bipolar disorder. On 1/15/2025 at 1:14 PM, V5 (Business Office Manager/BOM) stated R23's electronic health record (EHR) documented a diagnosis of bipolar disorder entered on 8/28/2024. V5 stated she was not employed at the time of this diagnosis, but does verbalize R23 should have been referred for a Level II PASRR. R23's Order Summary, dated 1/17/2025, listed active orders that included…
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 · D2025-01-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain range of motion for 1 of 1 (R52) residents reviewed for range of motion in a sample of 42. The Findings Include: R52's admission Record documents an admission date of 9/12/23. This same document includes the following diagnoses: major depressive disorder, anxiety disorder, other specified joint disorders, morbid obesity, and other intervertebral disc displacement, lumbar region. R52's quarterley MDS (Minimum Data Set), dated 2/23/24, documents in Section GG that her functional limitation in range of motion that she has an impairment on one side of lower extermity. R52's most recent quarterly MDS, dated [DATE], documents in Section C that R52 has a BIMS (Brief Interview of Mental Status) of 15, indicating R52 is cognitively intact. Section GG documents for functional limitation in range of motion that R52 has an impairment on both sides for lower extremities. Section GG also documents for self care that R52 is dependent 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 · D2025-01-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 1 (R52) residents reviewed for unnecessary medications in a sample of 42. The Findings Include: R52's admission record documents an admission date of 9/12/23. This same document includes the following diagnoses: major depressive disorder and anxiety disorder. R52's Minimum Data Set (MDS), dated [DATE], documents in section C, Cognitive Patterns, that R52 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R52 is cognitively intact. R52's January 2025 Order Summary Report includes the following medication orders: Ativan 1 milligram tablet by mouth every 6 hours as needed related to anxiety disorder. Ativan has a start date of 1/7/25 and an end date of 1/21/25. Buspirone 10 milligrams tablet by mouth two times a day related to anxiety disorder. This had an original start date of 9/12/23. Escitalopram 20 milligrams tablet one time a day related to major…
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 · D2025-01-17 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 provide meals at a palatable temperature when delivering hall trays for 3 of 3 (R59, R69, and R74) residents reviewed for food palatability in a sample of 42. The The findings Include: 1. R59's admission record documents an admission date of 6/19/24, and includes the following diagnoses: Diabetes Mellitus Type 2, anxiety disorder, pressure ulcer of left heel, muscle weakness, and unspecified open wound to foot. R59's quarterly Minimum Data Set (MDS), dated [DATE] Section C, documents a BIMS (Brief Interview of Mental Status) score of 15, indicating he is cognitively intact. On 1/15/25 at 12:06PM, R59 stated he chooses to eat in his room for all meals. R59 stated most of the time, all of his food is cold when it is delivered to him. R59 went on to state he sees the tray get delivered to the hallway, but there are times it takes over 20 minutes for the nursing staff to then get the trays passed out. 2. R69's admission record documents an admisison date…
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 · F2024-11-25 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 there was sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 78 residents currently residing at the facility. Findings Include: The facility Resident Matrix dated 11/14/24 documents 78 residents currently reside at the facility. 1. R1's admission Record, with a print date of 11/20/24, documents R1 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's Disease, atrial fibrillation, urinary incontinence, weakness, and dementia. R1's MDS (Minimum Data Set), dated 11/8/24, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive deficit. This same MDS documents R1 is at risk for pressure ulcers with treatments documented as pressure reducing device for chair and bed, turning and repositioning program, and application of ointments/medications. R1's current Care Plan documents a Focus area of, The resident has an ADL…
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 10 citations
- Potential for harm · E2024-11-25 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the shower rooms on 200 and 500 hall had hot water. This has the potential to affect all residents residing on halls 200 and 500. Findings Include: On 11/19/24 at 11:00 AM, this surveyor's and the facility's digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 11/19/24 at 11:03 AM, V1 (Regional Director of Operations) checked the water temperatures in the shower room at the shower head using a cup to hold the water on the 500 hall, and the reading was 79.7 degrees Fahrenheit. On 11/19/24 at 11:22 AM, V1 checked the water temperature in the shower room at the shower head using a cup on 200 hall, and the reading was 84.5 degrees Fahrenheit. R3's admission Record, with a print date of 11/20/24, documents R3 was admitted to the facility on [DATE] with diagnoses that include diabetes, morbid obesity,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-25 · tag F0602 — failed to protect residents from theft of their belongings — patternProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure residents were free from misappropriation of funds for 25 of 26 (R2, R5, R11, R21-R42 ) residents reviewed for misappropriation of funds in the sample of 42. Findings Include: A facility Initial Report documents: Date of incident 11/4/24. Under Status: At approximately 7:25 a (7:25 AM) it was reported by surveyor (name of surveyor) that she had a complaint about Administration at the facility stealing money. There were no specifics to the complaint, but the facility has opened an investigation into this matter. At this point there have been no reports of missing money. Quarterly trust statements were sent out on October 1, 2024, with no concerns reported. Investigation started, Medical Director, Local Police and Ombudsman have been notified. Final report will be sent within 5 days . After reviewing the trust, resident ledger, deposits, withdraw batches and bank statements, we do find some discrepancies with the trust. The local police have been updated on the findings at this point. Administrator (V4), resigned 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 · E2024-11-25 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure incontinence care was provided timely and shampoo/body wash was readily available for 6 of 6 (R1, R3, R8, R10, R11, and R16) residents reviewed for Activities of Daily Living in the sample of 42. Findings Include: 1. R3's admission Record, with a print date of 11/20/24, documents R3 was admitted to the facility on [DATE], with diagnoses that include diabetes, morbid obesity, neuromuscular dysfunction of the bladder, anxiety disorder, chronic pain syndrome, and pressure ulcer of right buttock. R3's MDS (Minimum Data Set), dated 10/18/24, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R3 is cognitively intact. This same MDS documents R3 is dependent on staff for toileting hygiene. R3's current Care Plan documents a Focus area of, The resident has an ADL (Activities of Daily Living) Self Care Performance Deficit. Date Initiated: 07/30/2024. This Focus area includes the following interventions. Transfer: Mechanical…
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 · D2024-11-25 · 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 residents were free from physical abuse for 1 of 3 (R12) residents reviewed for abuse in the sample of 42. Findings Include: A facility Initial Report on R12 documents, On 10/28/24 at approximately 0830 am (8:30 AM), CNA (Certified Nursing Assistant) reported that she witnessed an unwanted contact between resident and staff member to his right shoulder. The resident was immediately assessed for injuries and none noted. The staff member was immediately removed from the floor and schedule until further notice. The PCP/POA/Police Department (primary care physician/power of attorney) and other reporting authorities notified Under investigation the report documents, The investigation in to this matter was conducted, and this is the result and final report. The alleged abuser (Activity Director/V6) was interviewed and she provided a statement saying that she walked by R12 and he reached out and slapped her on the bottom. She stated that she tapped him…
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 · D2024-11-25 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegations of misappropriation of resident funds was reported to the Administrator for 1 of 26 (R4) residents reviewed for misappropriation of funds in the sample of 42. Findings Include: R4's admission Record documents R4 was admitted to the facility on [DATE], with diagnoses that include diabetes, pressure ulcer, anxiety disorder, and difficulty walking. R4's Minimum Data Set, dated [DATE] documents R4 has a Brief Interview for Mental Status score of 15, which indicates R4 is cognitively intact. An undated facility Initial Report documents, Date of incident: unknown: I received a report from a state surveyor that one of our residents (R4) is reporting having money missing from his wallet. After speaking with the surveyor I went to (R4's) room and asked him when this occurred and he told me one time was ten days ago and another time was Thursday of last week. This is the initial report with investigation and final to follow. This same report…
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 · D2024-11-25 · 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 interventions were implemented to prevent pressure ulcers and hand hygiene was performed per current standards of practice when administering treatments for 3 of 3 (R1, R4, and R7) residents reviewed for pressure ulcers in the sample of 42. Findings Include: 1. R1's admission Record, with a print date of 11/20/24, documents R1 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's Disease, atrial fibrillation, urinary incontinence, weakness, and dementia. R1's MDS (Minimum Data Set), dated 11/8/24, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive deficit. This same MDS documents R1 is at risk for pressure ulcers with treatments documented as pressure reducing device for chair and bed, turning and repositioning program, and application of ointments/medications. R1's current Care Plan documents a Focus area of, The resident has an ADL (Activities of Daily…
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 · D2024-01-26 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to care plan residents renal diets and fluid restriction for 2 of 18 residents (R11,R27) whose care plans were reviewed in the sample of 37. Findings include: 1. R11's Face Sheet documented an admission date of 9/20/23, and listed diagnoses including Acute Kidney Failure and Diabetes Type 2. R11's Physicians Order Sheet documented an order for hemodialysis Monday, Wednesdays, and Fridays at a local dialysis provider, and a diet order for a renal diet, low in fiber, with thin liquids and and a 1000 ml(milliliter) total per day fluid restriction. On 1/23/24 at 12:09pm, R11, who was alert and oriented, stated she is on dialysis and is to receive a renal diet and fluid restriction. R11's 12/20/23 Care Plan did not document problem areas, goals, or interventions related to the diet and fluid restriction. On 1/25/24 at 11:46am, V4, Care Plan Coordinator, stated she was not sure why R11's Care Plan did not address the renal diet and the fluid restriction, But it should have. 2. R27's Face Sheet documented an admission date to 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 · D2024-01-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide therapeutic diets for two residents on dialysis (R11, R27) of four residents reviewed for therapeutic diets in the sample of 37. Findings include: 1. R11's Face Sheet documented an admission date of 9/20/23, and listed diagnoses including Acute Kidney Failure and Diabetes Type 2. R11's Physicians Order Sheet documented an order for hemodialysis Monday, Wednesdays, and Fridays at a local dialysis provider, and a diet order for a renal diet, low in fiber, with thin liquids and and a 1000 ml (milliliter) total per day fluid restriction. On 1/23/24 at 12:09 pm, R11, who was alert and oriented, stated she is on dialysis and is to receive a renal diet and fluid restriction. R11 stated she is often served foods she knows she is not supposed to eat, such as bananas and potatoes. R11 stated when this occurs, she does not say anything to staff, but she does not eat the food item. R11 was observed eating her lunch, which consisted of a sloppy joe on bun, french fries, baked beans, and a snickerdoodle cookie. 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 · D2023-09-29 · tag F0805 — failed to prepare food in a form residents can eat — isolatedEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
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 mechanically altered diets were the appropriate consistency for two (R1 and R3) of seven residents reviewed for mechanically altered diets in the sample of seven. Findings include: 1. R1's Face Sheet documented diagnoses including Parkinson's Disease, Hypertension, and Chronic Kidney Disease. R1's Physicians Orders documented a 9/12/23 order for a mechanical soft diet with thin liquids and fortified foods and (nutritional supplement) shakes at all meals. R1's Minimum Data Set, dated [DATE], documented R1 requires extensive assistance from one staff member for eating, R1 has moderate deficits in cognitive functioning, and R1 requires a mechanically altered diet. A 9/14/23 Speech Therapy Evaluation authored by V11 (Speech Therapist) documented, Patient demonstrated difficulty swallowing with reports of coughing during noon meal on 9/13/23. It is still recommended that patient remain on the current ordered diet. An Illinois Department…
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 · D2023-09-29 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide nutritional supplements as ordered for 3 of 7 residents (R1, R2, R7) for therapeutic diets in the sample of 7. Findings include: 1. R2's Physicians Orders documented a Diet Order, dated 9/12/23, for a Diabetic diet, thin liquids, with health shake (nutritional supplement) at all meals. On 9/27/23 at 10:25am, R2, who was alert and oriented, stated for some reason, for the past two days there has been a carton of nutritional supplement on her lunch tray. R2 stated she was unaware this had been added to her diet, and does not know when it was ordered. 2. R7's Physicians Orders documented a 5/23/23 diet order for fortified pudding at lunch and supper and a (trade name) nutritional shake at every meal. On 9/26/23 at 10:15am, R7 was in his room with his family member (V4). R7 was awake and alert, but nonverbal. V4 stated R7 has dementia, and V4 comes daily to feed R7 lunch. V4 stated R7 is to receive fortified pudding and a nutritional shake at lunch, but often he doesn't. 3. On 9/27/23 at 12:45pm, V11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$11,660 in federal fines across 1 penalty.
- $11,660 — penalty dated 2025-01-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to WLC MANAGEMENT FIRM — 18 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.8 | +1.2 vs chain |
| Health inspection | 4 of 5 | 3.7 | +0.3 vs chain |
| Staffing | 3 of 5 | 1.8 | +1.2 vs chain |
| Quality measures | 2 of 5 | 1.5 | +0.5 vs chain |
The other 17 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WLC MANAGEMENT FIRM LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/01/2019 |
| STOUT, SCOTT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 02/01/2018 |
CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 70% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $384K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 145376. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-03, 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.