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Mount Sterling Health And Rehab Center

435 Camden Rd, Mount Sterling, IL 62353 · For profit - Limited Liability company · 80 certified beds · (217) 773-3377 Medicare & Medicaid certified

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Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$62,846 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2026
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $62,846 in federal fines (most recent 2026-01-10)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
216 Pittsfield Rd · (217) 773-3963 · Call to confirm hours
Pharmacy
200 Pittsfield Rd · (217) 773-2144 · Call to confirm hours
Grocery
125 E Main St · (217) 773-3376 · Call to confirm hours
Park
600 N Maple St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 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 fell from 5 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased11.6%13.4%15.4%better
Long-stay residents who lose too much weight8.3%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms41.1%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.4%0.1%0.1%worse
Long-stay residents with falls causing major injury1.3%3.1%3.3%better
Long-stay residents whose ability to walk worsened9.9%14.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.5%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine94.4%91.8%95.3%typical
Long-stay residents with pressure ulcers7.4%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control23.5%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table14.1%21.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.2%1.4%better
Short-stay residents given the seasonal flu vaccine84.1%63.1%79.4%typical
Short-stay residents rehospitalized after admission24.5%26.1%22.6%typical
Short-stay residents with an outpatient ER visit12.6%13.9%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.432.021.67better
Long-stay outpatient ER visits per 1,000 resident days2.222.221.80worse

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.

58.8% 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 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.8%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
52.9%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 52.9% 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 51 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 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.8%CMS range 44.5–70.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 6.8–14.710.7%Oct 2022–Sep 2024no 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 discharge52.9%56.6%Oct 2024–Sep 2025CMS 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 discharge56.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge52.9%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.7%CMS range 3.4–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS 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

0.39
RN hours/ resident / day
0.58
LPN hours/ resident / day
1.89
Aide hours/ resident / day
2.86
Total nurse hours/ resident / day
0.35
RN hoursweekends
54.2%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 66.2 residents a day — about 83% occupied, or roughly 14 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 2.86 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 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 2.43 hrs/resident/day on weekends vs 3.03 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.40 to 0.35 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2024-02-28)
8
at the previous standard inspection (2022-12-15)

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.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · J2026-01-10 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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 observation, interview, and record review the facility failed to de-escalate a resident's behaviors and protect a cognitively impaired resident from staff-to-resident physical abuse for one of three (R1) residents reviewed in the sample of four. These failures resulted in a staff member (V4/Registered Nurse) kicking a resident (R1), who has a diagnosis of Dementia and known physical behaviors, three times above the left hip on 11/1/25 after R1 exhibited behaviors towards V4, which caused R1 to experience psychosocial and physical harm of fear, mental anguish, and pain.These failures resulted in an Immediate Jeopardy:While the immediacy was removed on 1/3/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Abuse Policy dated 2/2025 documents, To provide guidance and procedures to the facility and staff to assure the 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to assess safety risks and provide supervision for one (R1) of three residents reviewed for falls in a total sample of six. Findings include:The facility's Transportation Policy dated 7/1/23 documents It is the facility's responsibility that any resident being transported by the facility vehicle will have a safe and secure transport.R4's medical record documents R4 was admitted to the facility on [DATE] with diagnoses to include Repeated Falls, Chronic Kidney Disease, Bipolar Disorder, Anxiety, Major Depression, and Intrahepatic Bile Duct Cancer. R4's Skilled Care assessment dated [DATE] at 1:56 PM documents R4 is alert and oriented to person and place, her memory is OK and she is able to recall the current season and she is in a facility.R4's care plan documents interventions dated 3/3/26 include Keep environment free from clutter, Reinforce use of assistive devices, Observe for unsteady gait and balance, and Instruct to avoid sudden…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 physician ordered pressure ulcer treatments were transcribed to the treatment administration records and provided as ordered by the physician for one of three residents (R2) reviewed for pressure ulcers in the sample of four.Findings include:The facility's Pressure Ulcer Prevention, Identification, and Treatment Policy dated 10/16/23 documents, Purpose: To provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment of pressure ulcers. Policy: The facility will initiate an aggressive treatment program for those residents who have pressure ulcers. Responsibility: It is the responsibility of the charge nurse/designee to care for pressure areas and provide treatments as ordered. Procedure: When a pressure ulcer is identified whether in-house, or upon a resident's admission, the area will be assessed using the skin and wound assessment and initial treatment started per physician's orders.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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-08-25 · tag F0679 — failed to provide activities — widespread
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to provide activities on weekends and evenings. This failure has the potential to affect all 67 residents residing within the facility. Findings include:The Administration Code Section 300.1410 Activity Program (undated) documents a) The facility shall provide an ongoing program of activities to meet the interests and preferences and the physical, mental, and psychosocial well-being of each resident, in accordance with the resident's comprehensive assessment. The activities shall be coordinated with other services and programs to make use of both community and facility resources and to benefit the residents. g) The facility shall provide a specific, planned program of individual (including self-initiated) and group activities that are aimed at improving, maintaining, or minimizing decline in the resident's functional status, and at promoting well-being. The program shall be designed in accordance with the individual resident's needs, based on past and present lifestyle, cultural/ethnic background, interests, capabilities, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-04-05 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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

    Based on interview and record review the facility failed to respond to resident call lights in a timely manner for nine of 11 Residents (R2, R3, R4, R5, R7, R8, R9, R10 and R11) reviewed for call light response in a sample of 11. Findings include: Facility Call Light Guidance Policy, dated 7/1/23, documents: to provide guidance to all Facility staff on the use, response and placement of call lights; Resident call lights shall be responded to within a reasonable amount of time; it is the responsibility of all staff to respond to call lights; and if responding staff is unable to meet the request/need of the Resident, staff shall leave the light on and elicit the assistance of appropriate staff. Facility Certified Nursing Assistant/CNA Job Description, undated, documents: the CNA provides each assigned resident with routine daily nursing care and services in accordance with the Resident's assessment and care plan; and will be accountable for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-10-05 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to ensure trash cans were emptied daily and resident rooms, floors, and bathrooms were clean and free of stains and debris for four of four residents (R1-R4) reviewed for housekeeping services in the sample of four. Findings include: The facility's Housekeeping Vendor's Deep Cleaning Procedures policy (undated) documents, Clean restroom by moving in a clockwise rotation from the restroom door. h. Toilet-Scrub and disinfect toilet bowl. Remove all stains and build-up. n. Remove all build-up from floor around bowl, door frame, corners, and edges. Dust mop and damp mop entire room. The facility's Resident Council Minutes dated 8-1-24, 9-5-24, and 10-3-24 document, Concerns that the rooms are not being cleaned well. Concerns about having to take out their own trash. On 10-4-24 at 9:10 AM, R1 and R3's floor in-between R1 and R3's beds had two golf-ball sized areas of dried feces. R1 and R3 had clothes and a four-by-four gauze with dried brown drainage lying on their closet floor. R1 and R3's corner of the closet had…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0644 — isolated
    Coordinate 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 follow PASARR (Preadmission Screening and Resident Review) requirements for one resident (R29) of three residents reviewed for PASARR in a total sample of 20. Findings Include: R29's Level II PASARR (Preadmission Screening and Resident Review) dated 8/8/23 documents You fall into the category of having a diagnosis that the PASRR program was designed to assess. Your condition is likely to require expert treatment in the future. That diagnosis is: A serious mental health condition. At this time, you meet PASRR inclusion criteria. You have a Level II PASRR condition of Depression Disorder which has impacted your functioning and need for ongoing treatment support. You also have the diagnoses of Anxiety Disorder, PTSD (Post Traumatic Stress Disorder) and Narcolepsy. Rehabilitative services: You will need to be provided the following services and/or supports Provision of a structured environment for those individuals who are determined to need such structure: Individual, group and family psychotherapy. R29's Care Plan dated…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the Facility failed to perform hand hygiene and prevent cross contamination, for three separate wounds, during wound/skin care for one of five Residents (R37) reviewed for wound/skin care in a sample of 20 Findings include: Facility Dry Dressing Policy, dated 7/2/23, documents: the purpose is to provide guidelines for the application of dry, clean dressings; perform hand hygiene, put on clean gloves, loosen tape and remove soiled dressing; pull glove over dressing and discard into plastic bag; perform hand hygiene, open dressing equipment using clean technique, place on clean field, perform hand hygiene and put on clean gloves, cleanse wound with ordered cleanser, if using gauze, use clean gauze for each cleansing stroke, clean from the least contaminated area to the most contaminated area; discard disposal items into the designated container; remove disposable gloves and discard into designated container; and perform hand hygiene. Facility Hand Washing Policy, dated 7/1/23, documents: to provide guidelines for adequate hand washing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the Facility failed to investigate a fall for one of four residents (R50) reviewed for falls in a sample of 20. Findings include: Facility Policy Accidents and Incidents, dated 07/01/23, documents: all accidents/incidents involving a Resident will be documented in Risk Management. The nursing team will complete an investigation with the root cause and new interventions; Section Responsibility documents it is the responsibility of the Charge Nurse to complete the accident and incident in (a computerized charting system), notify attending Physician and responsible parties and document accordingly. It is the responsibility of the DON/Director of Nursing/Designee to investigate and ensure appropriate completion, notification, and follow-up on all accidents and incidents; Section Procedure: Reporting documents Accident and Incidents, including injuries of an unknown origin, must be reported to the department supervisor, and an accident/incident report should be completed on the shift that the accident or incident occurred; Section titled Medical…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview the facility failed to provide any treatment or counseling for a residnet with a diagnosis of PTSD (Post Traumatic Stress Disorder) and failed to identify triggers for PTSD for one resident (R29) of three residents reviewed for PTSD in a total sample of 20. Findings Include: The Facility's undated Trauma Informed Care Procedure documents Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. R29's Care Plan dated 03/01/23 documents I suffered a traumatic life event. I was physically assaulted which resulted in bodily harm. I require ongoing support and intervention with a counselor. R29's Care Plan does not address any triggers or any situations for staff to avoid related to R29's PTSD. R29's Care Plan dated 09/01/23 documents This resident has a history that indicates they may have experienced significant trauma during their lifetime. Specifically, trauma related 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-28 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to wash their hands and change gloves between two different residents (R8 and R33) of four residents reviewed for personal cares in a total sample of 20. Findings Include: The Facility's Standard Precautions Policy dated 6/19/22 documents Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. On 2/26/24 at 1:30 PM, V4 (Certified Nurse Aide) rolled R33 to his side, touched his buttocks while pointing out multiple small open areas. V4 then rolled R33 to his back and used both gloved hands to roll back the foreskin on R33's penis and repeatedly touched the tip of the penis while indicating where small open areas were on the penis. After V4 covered R33 back up, she went directly to R8's bed without changing gloves or sanitizing hands in any way, rolled R8 to his…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2023-12-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure antipsychotics were utilized as abuse incident interventions without behaviors to warrant the use and obtain a stop date for a PRN (as needed) antipsychotic for one of one resident (R1) reviewed for antipsychotics in the sample of five. Findings include: The facility's Psychotropic Medications Policy, dated 7/1/23, documents, In accordance with federal and state regulations, it is the facility's policy that residents will not be given unnecessary medications. Residents shall only be given antipsychotic drugs when clinically indicated according to appropriate diagnosis and physician's order. On 12/18/23 at 12:45 p.m., R1 was alert sitting up in her low bed with her husband at her bedside feeding her lunch. R1 would periodically stop and start clapping her hands together. R1 interacted with V13 (R1's POA-Power of Attorney) appropriately, but confused. R1 was holding V13's hands. At no time did R1 become aggressive with V13. V13…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-20 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to maintain privacy and confidentiality of personal and health information for two residents (R8 and R9) of 4 residents reviewed for medical records in the sample of 10. Findings include: R8's Assessment signed by V13 (Nurse Practitioner) dated 7/1/22 at 1:52 PM, documents R8's personal information was uploaded into R1's electronic medical record. The information included the following: R8's date of birth , address, and phone number. It included that R8 has dementia due to Parkinson's Disease without behavioral disturbance, Anxiety, Chronic Diastolic Congestive Heart Failure, Diabetes Mellitus Type 2, and a Urinary Tract Infection. The record also went on to state that R1 was a new resident and included additional information concerning R8's plan of care, active problems, and physical exam. (This information was included with R1's electronic records that were to be sent to a facility R1 requested to transfer to.) On 9/19/23 at 11:23 AM, V2 (Director of Nursing) and V12 (Regional Support Nurse) came in with a laptop computer…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-15 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 accurately assess residents for the use of bed rails and ensure bed rails were not left in the up position for residents who could not turn or reposition independently in the bed for five of five residents (R21, R1, R22, R26, R18) reviewed for bed rail safety in a sample of 19. Findings include: A Bed Rails policy dated as revised 1/10/18 states that bed rails may be used under certain circumstances which includes to, Assist in transfer into and out of their bed. To enable the resident('s) ability to independently make subtle position changes for comfort and pressure relief. To enable the residents (') ability to participate with staff in assistance to turn and reposition. This policy does not address residents who cannot independently utilize bed rails to reposition, or other safety concerns including impaired cognition or residents' individualized entrapment risks. 1. A list of R21's current diagnoses includes Down's Syndrome, Generalized…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-15 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to complete a comprehensive MDS (Minimum Data Set) assessment within 14 days following a significant change in condition for one of one residents (R18) reviewed for change in condition in the sample of 19. Findings include: The CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Manual dated 10-1-19 documents, A significant change in status assessment must be completed no later than 14 calendar days from determining a significant change in a resident's status occurred. A significant change in assessment is required when the resident has an improvement in more than one area of health status or a decline in more than one area of health status that is not expected to resolve within two weeks. A significant change in status assessment is also appropriate if there is a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement. This may include two changes within a particular…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-15 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure 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 develop and implement restorative programs and a plan of care to treat R18's decline in Activities of Daily Living (ADL's) for one of one resident (R18) reviewed for ADL decline in the sample of 19. Findings include: The facility General Requirements for Nursing and Personal Care policy dated 6-29-11 documents, The facility shall provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with each resident's comprehensive care plan. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. Restorative measures shall include, at a minimum, the following procedures: All nursing personnel shall assist and encourage residents so that a resident's abilities in activities of daily living do not diminish unless circumstances of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-15 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident's toenails were trimmed for one of two residents (R21) reviewed for activities of daily living (ADL) care in a sample of 19. Findings include: A facility General Requirements for Nursing and Personal Care policy (undated) states, Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident, and A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal hygiene. In addition, this policy states, Each resident shall have proper daily personal attention, including skin, nails, hair, and oral hygiene, in addition to treatment ordered by the physician. A list of R21's current diagnoses includes Down's Syndrome, Generalized Muscle Weakness, Muscle Wasting and Atrophy. R21's Minimum Data Set (MDS) assessment dated [DATE] documents that…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 prevent the development of a Deep Tissue Injury (DTI) for one of one resident (R21) reviewed for pressure ulcers in a sample of 19. Findings include: A Wound and Ulcer Policy and Procedure dated as revised 1/10/18 states, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management, and All residents will be assessed to determine the degree of risk of developing a pressure ulcer using the Braden Scale-Ulcer Risk Assessment. This policy states that protocols for pressure ulcer prevention are, based upon the needs and condition of the resident. In addition, this policy defines a DTI as, Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear, and The wound may further evolve and become covered by thin eschar…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-15 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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 ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one of one residents (R26) reviewed for range of motion in a sample of 19. Findings include: A Restorative Program Checklist dated 6/26/13 states, A restorative assessment is completed prior to implementing the (restorative) program and at least quarterly thereafter, and Measurable objectives & interventions are documented in the care plan and clinical record. A Contracture Prevention Program policy dated 1/15/11 gives as its objectives, 1. To maintain residents at the highest level of physical functioning possible. 2. To stimulate circulation and prevent edema. 3. To prevent fixation of a joint for long periods of time. 4. To prevent atrophy of muscles. In addition, this policy states, The plan of care established by physical therapy or nursing when a contracture…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to document behaviors to justify the use of anti-psychotic medications and failed to implement non-pharmacological behavioral interventions prior to the use of anti-psychotic medications for one of three residents (R27) reviewed for anti-psychotic medications with the diagnosis of Dementia in the sample of 19. Findings include: The facility's Psychotropic Medication policy dated 11-28-17 documents, Intent: Residents are free from unnecessary psychotropic medication use. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, and psychosocial needs. Indications for use for psychotropic medication may include but not limited to 1. Expressions or indications of distress. 2. Symptoms are clinically signification that is causing a functional decline. 3. Non-pharmacological approaches were implemented and not effective or were clinically contraindicated. Behavioral symptoms present a danger 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-10-07 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 attempt alternatives prior to the use of bed rails, document the risk of injury with the use of bed rails, document interventions to decrease the risk of injury, and to keep side rails down or off the bed for residents evaluated not to use bed rails for six of six residents (R3, R14, R18, R22, R32, R36) reviewed for bed rails in the sample of 24. Findings include: The Facility's Bed Rails policy dated 1/10/2018, states, Prior to the use of bed rails for a resident, the facility will document assessment of use, obtain Physician orders for use, and obtain consent from the responsible party or (Power of Attorney for Health Care). When bed rail consent is received, the facility will utilize the rails designated on the assessment at times when the resident is in bed unless otherwise specified. On 10/04/21 at 11:43 a.m., R3's bed had bilateral quarter bed rails in an upright position. On 10/6/21 at 1:30 p.m., R3 was lying in bed with bilateral…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-10-07 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident had prescription eyeglasses to maintain his visual function for one of one resident (R29) reviewed for vision/hearing in the sample of 24. Findings include: R29's Care Plan dated 10-5-21 documents, I (R29) have impaired visual function related to my diagnosis of Glaucoma and a detached retina of my right eye. I wear prescription eyeglasses daily to help correct my visual deficits. Due to my cognitive impairments, my visual acuity is hard to assess. I am able to see/follow large objects without difficulty and I am able to make eye contact with staff when I am wearing my glasses. I will maintain optimal quality of life within limitation imposed by my visual function by continuing to watch TV (Television) daily and looking out my bedroom window to watch the birds. Arrange consultation with my eye care practitioner as required/requested. (Staff) will have to put my eyeglasses on me each morning and remove them at bedtime.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-12-15 · tag F0847 — widespread
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to state in their arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. The facility also failed to have the resident, or their representative acknowledge if they understood the agreement. This had the potential to affect all 37 residents residing in the facility. Findings include: The facility's Arbitration Agreement between Facility and Resident is part of the admission Contract. The Mediation/Arbitration is in Section N on page ten of the admission Contract. The resident or their representative is required to initial after this section. The last page of the Contract, page 16, documents The undersigned acknowledge that each has read and understood this Contract, and that each voluntarily consents to all its terms. I further understand that I have the ability to refuse to enter into this contract and instead, remove the Resident from 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.

    Administration Deficiencies · Deficient, Provider has date of correction

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

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$62,846 in federal fines across 2 penalties.

  • $44,418 — penalty dated 2026-01-10
  • $18,428 — penalty dated 2025-05-07

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 SUMMIT HEALTHCARE CONSULTING — 9 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 →

RatingThis homeChain avg
Overall 1 of 52.6-1.6 vs chain
Health inspection 2 of 53.1-1.1 vs chain
Staffing 1 of 51.3-0.3 vs chain
Quality measures 4 of 52.9+1.1 vs chain
The other 8 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 / managerTypeRoleShareSince
SC ILLINOIS HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2023
APOGEE TROrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2023
SC ILLINOIS I TBD HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2023
BRIDGMAN, NIKKIIndividualW-2 MANAGING EMPLOYEEsince 07/01/2023
LICHTMAN, SHALOMIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023
LIGHT MAN LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023

CMS files one row per role, so the 7 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

4 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.

$2.4M
Net patient revenuemost recent cost report
+1.3%
Operating marginrevenue minus expenses
$278K
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 11%Other / private 17%

About 71% 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 $278K paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

$271per resident / day
operating cost
$8,228per month
≈ monthly operating cost
$274per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

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 145820. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-28, 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.

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