Allure Of Mt Carroll
1006 North Lowden Road, Mount Carroll, IL 61053 · For profit - Corporation · 72 certified beds · (815) 244-7715 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited May 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, 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
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 4 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 | 25.6% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.0% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.7% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.5% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 31.6% | 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 | 22.7% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 19.0% | 18.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.0% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 25.0% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 19.6% | 21.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.1% | 2.2% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 56.9% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 30.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 5.2% | 13.9% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.81 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.46 | 2.22 | 1.80 | better |
* 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.
53.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 4.9% 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 41 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 0.23 therapist hours per resident per day in 2025Q4 — more than 31% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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 14% — 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 | 53.9%CMS range 44.9–63.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 5.6–13.4 | 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 | 4.9% | 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 | 17.1% | 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 | 7.3% | 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 | 88.0% | 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 | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 8.0%CMS range 4.3–13.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.08 | 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 72 beds and averages 56.7 residents a day — about 79% occupied, or roughly 15 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.54 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.99 hrs/resident/day on weekends vs 3.37 on weekdays — 11% thinner on weekends. RN hours go from 0.39 to 0.29 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 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.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · G2024-05-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement weight loss prevention interventions prior to a resident (R32) experiencing a significant weight loss. This failure resulted in R32 experiencing a significant weight loss of 9.6% in three months. This failure applies to 1 of 5 residents (R32) reviewed for weight loss in the sample of 14. The findings include: R32's admission care plan dated 12/29/23 showed R32 was at risk for malnutrition and weight loss related to her diagnoses of dementia, dysphagia (trouble swallowing), depression, and a history of pneumonia. R32's Weights and Vitals Summary showed R32's weights as 156 pounds (lbs.) on 2/6/24, 151 lbs. on 3/4/24, 147 lbs. on 4/17/24, and 141 lbs. on 5/3/24. The record showed R32 experienced a significant weight loss of 9.6% in three months, from 2/6/24 - 5/3/24. R32's Mini Nutritional assessment dated [DATE] showed R32 was deemed at risk for malnutrition and weight loss by V3 (Registered Dietician/RD). The assessment showed V3 RD documented…
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 · E2026-07-09 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility to store controlled substances in a separately locked, permanently affixed storage container. This applies to 7 of 7 residents (R3, R6, R8, R40, R11, R53, and R57) reviewed for controlled substances in the sample of 33. The findings include:On 7/8/26 at 1:03 PM, the facility's medication room was reviewed with V3 (Assistant Director of Nursing). The door to the room was locked and within the room was a medication refrigerator. In the refrigerator (refrigerator was not locked and had no lock) was a lockbox, which V3 was able to remove from the refrigerator without a key (it was not affixed to the refrigerator). V3 stated the lock box contained lorazepam (an antianxiety mediation) and the refrigerator did not have a lock. On 07/8/2026 at 2:53 PM, V2 (Director of Nursing) stated narcotics as well as lorazepam need to be locked due to the increased risk of drug diversion. V2 stated controlled substances need to be double locked; however, V2 stated it was her understanding the door to the medication room was the permanently…
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 · D2026-07-09 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect a resident's rights by ensuring his private space was protected/honored for 1 of 1 resident (R41) reviewed for resident rights in the sample of 33.The findings include:On 7/7/26 at 1:36 PM, R41 was sitting in the recliner in his room. R41 stated R5 wanders the halls in her wheelchair, comes into his room and has gone through his dresser and closet. R41 stated the last time R5 did this was 4 days ago. R41 stated R5 has done this before, and he has reported it. R41 stated he has fallen asleep, gets the feeling someone is looking at him and R5 is in his room. R41 stated when he was younger, he was jumped, mugged and lost his eyesight in one eye from the incident. R41 stated since then when someone gets close to him it puts him in a defensive mood. R41 stated it is upsetting. R41 stated a lot of people have dementia, can't help what they do but he feels the facility should watch R5 closer.R41's current Care Plan dated 5/14/26 showed,…
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 · D2026-07-09 · 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 document a resident's discharge to the hospital and failed to issue a bed hold for 1 of 2 residents (R17) reviewed for discharge in the sample of 33. The findings include: R17's admission record documents she was admitted on [DATE] following a cerebral infarction with left side paralysis.R17's census record shows she was discharged to the hospital on 4/28/26 and returned to the facility on 5/6/26. A review of R17's progress notes for 4/28/26 shows no documentation of her transfer out of the facility, and no progress notes regarding her discharge to the hospital. On 7/08/2026 at 1:00 PM, V6 (Registered Nurse) said she believed R17 was going back to the hospital to have something done and was found to have a urinary infection, so she was admitted to the hospital for IV (intravenous) antibiotics. V6 said R17 was in the hospital for awhile to have the infection cleared up before her procedure. She said the notes should show how she left, where she went to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-09 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is 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 ensure a resident's facial hair was shaved for 1 of 1 resident (R10) reviewed for activities of daily living in the sample of 33. The findings include: On 7/7/26 at 1:05 PM, R10 was sitting in his wheelchair in his room. R10 had prosthesis with a hook end to his left arm. R10 had thick facial stubble to his face. R10 stated he would like to be shaved. R10 stated at home he would shave himself everyday but he can't do it any longer due to his eyesight. R10 stated it had been a few days since he had been shaved by staff. On 7/9/26 at 9:24 AM, V9 (Certified Nursing Assistant) stated residents are shaved as needed. Most of the men are shaved daily and should be. V9 stated they all get shaved on shower days. V9 stated she has not had any residents refuse to be shaved. V9 confirmed they honor the resident's preferences. On 7/9/26 at 12:48 PM, V3 (Assistant Director of Nursing) stated male residents are usually shaved first thing in the morning.…
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 · D2026-07-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to ensure a resident had oxygen for 1 of 1 resident (R6) reviewed for oxygen in the sample of 33.The findings include:On 7/8/2026 at 11:20 AM, R6 was sitting in a wheelchair in her room with oxygen on via nasal canula. R6 appeared short of breath and her respiratory rate was 30 breaths per minute. The nasal cannula was attached to a portable tank on the back of her wheelchair and the meter on the tank showed it was empty. R6 had an oxygen concentrator in her room. R6 stated they tell her to breathe in through her nose and out through her mouth when she is short of breath, but she can't breathe though her nose if there is no oxygen. Staff were alerted that R6 needed help. On 7/8/26 at 11:31 AM, V10 (Registered Nurse/RN) checked the portable tank on the back of R6's wheelchair and confirmed the oxygen tank was empty. V10 switched R6's nasal cannula over to the concentrator in her room and turned it on so she received oxygen at 2 liters per nasal cannula. V10 stated she did not realize R6 had returned from an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-07-09 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to follow the posted menu for residents with a puree diet for 3 of 3 residents (R46, R53, R57) reviewed for diets in the sample of 33. The findings include:On 7/7/26 at 9:45 AM, V7 (Cook) said the facility had 3 puree diets to prepare for the noon meal. She said the kitchen purees 2 items for the meal. She said the lunch meal for today was Swiss steak, peas, garlic mashed potatoes, bread and butter.The facility list of residents on pureed diets included R46, R53, and R57.The facility menu for the noon meal shows creamy Swiss steak, garlic mashed potatoes, buttered peas, bread/margarine and an iced oatmeal cookie bar.On 7/7/26, V7 was observed pureeing the Swiss steak and peas in the robot coupe and placed them into the steamer. V7 did not puree the iced oatmeal cookie bar. During the lunch service, R57 was observed to have applesauce in place of the oatmeal cookie bar. V7 said the kitchen does not puree the desserts. The staff will replace it with applesauce, pudding or ice cream. V7 said she was always told 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 · D2026-07-09 · 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
Based on observation, interview and record review the facility failed to prepare puree diets according to the recipe for 3 of 3 residents (R46, R53, R57) reviewed for puree diets in the sample of 33. The findings include: On 7/7/26 at 9:45 AM, V7 (Cook) said the facility had 3 puree diets to prepare for the noon meal. She said the kitchen purees 2 items for the meal. She said the lunch meal for today was Swiss steak, peas, garlic mashed potatoes, bread and butter.The facility list of residents on pureed diets included R46, R53, and R57.The facility menu for the noon meal shows creamy Swiss steak, garlic mashed potatoes, buttered peas, bread/margarine and an iced oatmeal cookie bar.On 7/7/26, V7 was observed placing the Swiss steak into the robot coupe. Once the steak was pureeing, V7 added cold milk to the mixture. Once she finished, she placed the puree steak back into the steamer. At 10:30 AM, V7 checked the reheating temperature of the steak, and it was 148 degrees. She said the temperature should be 165 degrees to be served. The puree recipe for creamy Swiss steak shows after…
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 before2026-07-09 · 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 have proper signage for residents on Enhanced Barrier Precautions (EBP). This applies to 3 of 3 residents (R6, R9, R52) reviewed for EBP in the sample of 33. The findings include: 1. R9's Face Sheet showed R9 was admitted to the facility on [DATE]. R9's Face Sheet showed she had a tracheostomy (opening in the throat to by pass the nose and mouth). On 7/8/26 at 11:10 AM, 7/9/26 at 11:03 AM, and 7/10/26 at 9:07 AM, R9's door had no visible signage for enhanced barrier precaution. On R9's door was a yellow cubby rack containing personal protective equipment (PPE). R9's Care Plan (dated 4/24/26) showed, The resident required Enhanced Barrier Precautions r/t (related to) tracheostomy.place signage s on doors of isolation precaution rooms. R9's physician orders showed an active order, May use EBP per policy as needed for indwelling medical devices. On 7/9/26 at 8:17 AM, V3 (Assistant Director of Nursing/Infection preventionist) stated residents…
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 · E2024-05-22 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure 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
Based on observation, interview, and record review the facility failed to provide residents receiving puree diets with smooth consistency to 5 of 5 residents (R15, R6, R18, R20, R25) receiving pureed diets in the sample of 14. The findings include: The Facility provided a document entitled Diet Type Report, dated 5/20/24 show R15, R6, R18, R20, and R25 were receiving pureed textured diet. On 5/20/24 at 11:50 AM, the facility provided a test tray of puree diets that included pureed lasagna, pureed garlic bread, and pureed mixed vegetables. The pureed garlic bread was thick, chunky, and clumpy, and the pureed mixed vegetables was watery, and required chewing. V15 (Dietary Manager) who was with the surveyor during the test tray process also tasted the pureed test tray. After tasting, V15 pointed to the pureed garlic bread and stated, this is so thick, it needs more liquid to get the texture of a mashed potato. V15 said the pureed mixed vegetables can be thickened and needed to be smoother. Pureed foods should be smooth in consistency. On 5/20/2024 at 11:00 AM, V16 (Cook) said a puree…
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 · D2024-05-22 · 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 obtain a physician's order, failed to obtain consent, and failed to perform an assessment for a resident using a seat belt in a motorized wheelchair for one of one resident (R44) reviewed for restraints in the sample of 14. The findings include: R44's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including muscle weakness, contractures to both knees, tracheostomy status, hemiplegia, malnutrition, anxiety disorder, and contracture to her left hand. On May 21, 2024 at 10:10 AM, R44 was in her room in her motorized wheel chair. R44 had a seat belt in place to her lower abdomen. R44 said she uses the seat belt because she slides out of the chair. The Self-Releasing Seat Belt Informed Consent for Use was signed by R44 on May 21, 2024. R44's Restraint Enabler was entered on May 21, 2024 at 3:41 PM. R44's Order Summary Report does not show any orders for a self-releasing seat belt prior to May 21, 2024. R44's Care…
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 6 citations
- Potential for harm · D2024-05-22 · 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 reassess a resident for safe swallowing after the resident had a choking episode in the facility. The facility failed to supervise a resident, with a history of falls, while the resident was seated on the toilet. The facility failed to ensure residents were transferred by staff in a safe manner. These failures apply to 3 of 14 residents (R14, R23, R42) reviewed for safety and supervision in the sample of 14. The findings include: 1. R14's admission Record showed R14 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, dementia, and cognitive impairment. R14's Progress Note dated 5/19/24 showed, Resident found to be purple in color with airway obstruction. Performed Heimlich maneuver, after a few thrusts resident gasped for air. Resident sat in wheelchair and was tearful. The note showed R14 choked on her evening medications. R14 was not sent to the hospital for an evaluation after the incident. R14's physician 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 · D2024-05-22 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to perform peri care in a manner to prevent urinary tract infections for one of six residents (R1) reviewed for peri care in the sample of 14. The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and history of falling. R1's Care Plan initiated November 29, 2023 shows the resident uses disposable briefs. Change every two hours and as needed. On May 20, 2024 at 12:57 PM, V9 and V10 (Certified Nursing Assistants/CNA) provided incontinence care for R1. R1's incontinence brief was saturated with urine and a large amount of stool. V10 CNA wiped a large amount of stool from R1's buttocks with a thin wet wipe. R1's stool was visible through the wet wipe. V10 folded the wet wipe in half and wiped R1's stool from her buttocks again. V10 folded the wet wipe a second time and wiped 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 · D2024-05-22 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
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 measure the external length of a peripherally inserted central catheter (PICC) for 1 of 2 residents (R52) reviewed for intravenous (IV) access in the sample of 14. The findings include: R52's Hospital Discharge Instructions dated 4/26/24 showed R52 had a PICC line placed to receive antibiotics for osteomyelitis (bone infection). On 05/20/24 at 12:30 PM, R52 had a PICC line to her right upper arm. R52 said she had a bone infection in her back and was getting IV antibiotics. R52 said the facility had been doing weekly dressing changes to her PICC line. However, R52 said she did not believe the facility was measuring the external length of the PICC. On 05/21/24 at 11:39 AM, V2 (Director of Nursing) said PICC measurements are done to see if the PICC has migrated. V2 added the measurements are documented in the Treatment Administration Record (TAR). R52's TAR showed the PICC dressing was changed 5/2/24, 5/9/24, and 5/16/24. There was no documented PICC measurements on the TAR. The facility's PICC/Midline/CVAD…
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 before2024-05-22 · 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 perform hand hygiene and change their gloves in a manner to prevent cross contamination for one of 14 residents (R1) reviewed for infection control in the sample of 14. The findings include: R1's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and history of falling. R1's Care Plan initiated November 29, 2023 shows the resident uses disposable briefs. Change every two hours and as needed. On May 20, 2024 at 12:57 PM, V9 and V10 (Certified Nursing Assistants/CNA) provided incontinence care for R1. R1's incontinence brief was saturated with urine and a large amount of stool. R1 was laying on her back when V10 folded R1's incontinence brief in between her legs. There was stool noted to R1's front peri area. V10 then touched R1's body to help her to turn onto her right side. V10 did not change 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 · D2024-05-01 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect 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 failed facility failed to ensure residents' money were not taken from their rooms which apples to 2 or 9 residents (R1, R2) reviewed for Misappropriation in a sample of 9. The findings include: The facility's Final Incident Report dated 4/30/24 showed the facility was able to verify R1 had at least $160 and R2 had at $33 missing from their rooms. This report showed the money was not recovered during the investigation. On 5/1/24 at 10:00 AM, V1 (Administrator) stated on 4/23/24 it was reported to her R1 made an allegation of missing money in her room. After talking with R1 and R1's family who was present, it was determined R1 had at least $160 dollars missing from her nightstand. The next morning while the investigation was ongoing R2 made the allegation she was also missing money from a bag kept in her room. R2's family was able to confirm R2 had $33 dollars which was last seen in R2's bag. The conclusion of the investigation was R1 and R2 had money removed from their rooms. V1 stated they had suspected a staff member (V11 Certified Nursing…
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 · D2024-05-01 · 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 contact law enforcement timely when an allegation of misappropriation occurred in the facility which applies to 2 of 9 residents (R1, R2) reviewed for misappropriation reporting is a sample of 9. The findings include: The facility's Final Incident Report showed on 4/23/24 R1 reported approximately $160 was missing. This report showed on 4/24/24 R2 reported missing $33 dollars. This report did not indicate the local police were contacted. On 5/1/24 at 10:00 AM, V1 (Administrator) stated she did not contact the local police for the missing money at the time of R1 and R2's allegations. V1 stated she had contacted the local police today (5/1/24). On 5/1/24 at 1:35 PM, V9 (local police officer) stated they had not been contacted by the facility prior to today (5/1/24) for an allegation of missing resident money. V9 stated it was reported to V9, R1's money was found to be missing on 4/23/24 and R2's money was reported missing on 4/24/24. The facility's Abuse Policy dated 2/1/24 showed reporting of all alleged violations 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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to ALLURE HEALTHCARE SERVICES — 15 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 | 2.6 | +1.4 vs chain |
| Health inspection | 5 of 5 | 3.1 | +1.9 vs chain |
| Staffing | 1 of 5 | 1.7 | -0.7 vs chain |
| Quality measures | 3 of 5 | 2.6 | +0.4 vs chain |
The other 14 homes this chain runs (chain average 2.6★, 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 |
|---|---|---|---|---|
| MN1 MANAGEMENT CORP | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 07/01/2019 |
| GOLDBERG, JEREMY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 07/01/2019 |
| OSEROFF, MEYER | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 33% | since 07/01/2019 |
| NUDELL, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 33% | since 07/01/2019 |
| ALLURE MT CARROLL PROPERTY, LLC | Organization | 5% OR GREATER SECURITY INTEREST | — | since 07/01/2020 |
| NEAS, STEPHANIE | Individual | W-2 MANAGING EMPLOYEE | — | since 02/01/2021 |
| NUDELL, SHIRA | Individual | CORPORATE OFFICER | — | since 12/01/2023 |
| ALLURE HEALTHCARE SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2019 |
| MEYER, SAMANTHA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2023 |
CMS files one row per role, so the 10 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $921K paid to related parties — landlords or management companies under common ownership — equal to about 15% 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 2026-09-01 — CMS provider number 145770. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-09, 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.