Mount Vernon Countryside Manor

Location & what’s nearby

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

Quality measures — how residents actually fare

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.

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.

52.3% 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 286 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 38.3% 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 128 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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.

Staffing

How full it usually is: this home is certified for 91 beds and averages 77.5 residents a day — about 85% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.92 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 1.90 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 2.81 hrs/resident/day on weekends vs 2.96 on weekdays — 5% thinner on weekends. RN hours go from 0.42 to 0.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% 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.

28 citations, most serious first. The 14 most serious are shown; the remaining 14 are one tap away and print in full.

• Actual harm · Gcited before2025-01-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide 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 dietary supplements as ordered for 4 (R39, R44, R45 and R63) of 8 residents reviewed for nutrition in a sample of 36. This failure resulted in R63 experiencing a 7.88 percent weight loss within one month. Findings include: 1. R63's Resident Face Sheet documented an admission date of 3/13/24 with diagnoses including: dementia, underweight, mild protein-calorie malnutrition, muscle wasting and atrophy. R63's 12/13/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 1, indicating R63 had severe cognitive impairment. R63's Progress Note dated 12/19/24 from V3 (Dietician) documents, Note r/t (related to) wound. Resident has skin tear to R (right) hip/buttock. Wt (Weight) 104# (pounds), usual for resident and stable. Diet order: regular, regular texture, thin liquids. Health shake one daily. Dietary intake is poor to fair. Recommend health shake BID (twice daily) and vit C 1000mg (milligrams) r/t wound healing.…

  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
• Actual harm · Gcited before2024-08-27 · 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 use the appropriate size shower chair for 1 (R1) of 4 residents reviewed for accidents in the sample of 4. This failure resulted in R1 sliding down in the chair into the open part, causing an acute impacted fracture of the left femoral neck. This past non-compliance occurred between 07/10/2024 and 07/16/2024. The findings include: R1 ' s Resident Face Sheet documents an initial admission date to the facility of 05/07/2022 with diagnoses including unspecified dementia, anorexia, hypokalemia, chronic obstructive pulmonary disease, anxiety, major depressive disorder, arthritis, restlessness, agitation, and pseudobulbar affect. Additional diagnoses include acute impacted fracture of the left femoral neck dated 07/10/2024. R1 ' s MDS (Minimum Data Set) section C, dated 06/21/2024, documents that R1 has a BIMS (Brief Interview of Mental Status) of 05 indicating R1 has severe cognitive impairment. The same MDS section GG documents that R1 has impairment in both sides of lower extremities (hip, knee, ankle, foot) and uses a…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Actual harm · G2024-03-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to provide timely physician notification of symptoms of a urinary infection and timely collection of specimens for 1 (R22) of 1 resident reviewed for Urinary Tract Infections in the sample of 60. This failure resulted in R22 experiencing untimely treatment of a Urinary Tract Infections with symptoms of pain and burning expressed by R22 beginning on 2/15/24, with antibiotic treatment not initiated until 2/28/24. Findings Include: R22's face sheet documents an admission date of 12/29/17 to the facility and includes the following diagnoses: major depressive disorder, need for assistance with personal care, and disorder of kidney and ureter. R22's most recent completed MDS (Minimum Data Set) dated 11/7/23 Section C documents a BIMS (Brief Interview of Mental Status) score of 15, indicating that R22 is cognitively intact. Section GG for toileting hygiene, shower/bathe self and personal hygiene are coded as needing substantial/maximal assist. In this same Section GG is coded as being dependent for toilet transfers. On 2/27/24 at…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-02-06 · 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 ensure residents who are transferred with a patient whole body lift machine are transferred safely and in accordance with the facility's lift machine policy for 1 of 3 (R1) residents reviewed for accidents in a sample of 9. This failure resulted in R1 falling while being transferred with the patient lift machine and sustaining moderate to large volume left scalp hematoma, acute minimally displaced fracture of C7 vertebral body, acute mildly displaced fracture of T1 vertebral body, and non-displaced fracture of the right posterior first rib. This past non-compliance occurred from 12/16/2023 to 12/18/2023. Findings include: R1's EHR (Electronic Health Record) documents an admission to this facility on 12/8/2021 with diagnoses of Chronic Respiratory Failure, Peripheral Vascular Disease, Atherosclerotic Heart Disease, Chronic Venous Hypertension, Lymphedema, Morbid Obesity, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hearing Loss among others. R1's MDS (Minimum Data Set) dated 12/4/2023 under section GG…

  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 · Past Non-Compliance
• Potential for harm · Fcited before2026-03-27 · tag F0761 — failed to label and store drugs safely — widespread
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a medication cart was kept locked when out of staffs visual control. This has the potential to affect all 83 residents living at the facility. The findings include: On 03/25/2026 at 8:16 AM, V6 (Licensed Practical Nurse) prepped medications, left the cart unlocked and went down the hallway to room [ROOM NUMBER] leaving the unlocked cart out of her visual control. On 03/25/2026 at 8:22 A.M. V6 returned to the medication cart which remained unlocked. On 03/25/2026 at 12:02 P.M. V6 was observed at the end of 300 hall by the nurse's station talking with a resident. V6's medication cart for 300 hall was observed to be in the middle of the hallway unlocked. On 03/25/2026 at 12:05 P.M. V1 (Administrator) was observed walking down 300 hall, stopping at the medication cart and locking it.On 03/25/2026 at 12:11 PM, V6 stated she realized she left the cart unlocked after we had walked away and entered the resident's room. V6 stated she knows…

  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 · Fcited before2026-03-27 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review the facility failed to ensure the kitchen was clean and sanitary. This has the potential to affect all 83 residents residing in the facility. The Findings Include:During the lunch meal service on 3/24/26 at 11:30 AM the following observations were made: the cart that holds the clean plates for meal service was full of crumbs/old food debris, open shelves under preparation tables were dusty with food crumbs/dried drink spills, the top of the convection oven was dirty with food debris and grease buildup, the stationary cabinets underneath were littered with dropped dishes/paper trash/dirt, gnats were seen throughout the kitchen, underneath the juice machine was spilled dried juice, the floor appeared to be sticky and appeared to not have been mopped under the carts and stationary tables. On 3/24/26 corn meal was left open to air in the dry storage area from 9:00 AM until 2:00 PM. On 3/24/26 boxes were found in the dry storage area; some were empty stacked up and some were full sitting on the ground at 9:00 AM and still remained at 2:00…

  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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-27 · tag F0550 — failed to protect resident dignity and rights — isolated
  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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to treat residents with dignity during mealtimes for 1 of 1 resident (R34) reviewed for dignity in a sample of 34. Findings included:R34's admission Record documented an admission date of 2/13/24 with diagnoses including nontraumatic chronic subdural hemorrhage, Alzheimer's disease, major depressive disorder, cognitive communication deficit, and dysphagia, unspecified. R34's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 01, showing R34 had severe cognitive impairment. R34's Care Plan documented a focus area of sometimes feels lonely or isolated from others with interventions that included to observe for changes in appetite, signs of withdrawal, crying, and tearfulness, decrease in social interaction and encourage resident to keep involvement of choice. R34's Progress Note by V19 (Social Service Director/SSD) dated 2/13/2026 documented quarterly social service assessment completed, R34 alert…

  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 · D2026-03-27 · 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 interview and record review, the facility failed to maintain a functional status of mobility for 1 (R34) of 1 residents reviewed for ADL (Activities of Daily Living) in the sample of 34. Findings included:R34's admission Record documented an admission date of 2/13/24 with diagnoses including muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle weakness (generalized), other abnormalities of gait and mobility, nontraumatic chronic subdural hemorrhage, and Alzheimer's disease. R34's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 01, showing R34 had severe cognitive impairment. This same document under Section GG0115: Functional Limitation in Range of Motion (ROM) documented an impairment to both sides of the lower extremities and Section O0500 Restorative Nursing Programs of 0 days completed for walking. R34's Care Plan documented a focus area of needing verbal cues and substantial to dependent staff assist for activities of daily…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-27 · 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 interview, observation, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (R46) of 18 residents reviewed for position and mobility in the sample of 34. The Findings Include: R46's face sheet documents R46 was recently readmitted to the facility on [DATE]. The diagnoses listed include displaced intertrochanteric fracture of left femur, dementia, conversion disorder with seizures, hypertensive chronic kidney disease, mixed hyperlipidemia, hypothyroidism, chronic obstructive pulmonary disease, and Parkinson's Disease. R46's current orders document on 09/03/2025 an order for restorative active range of motion to be completed 6-7 times a week every shift. R46's MDS (Minimum Data Set) dated 02/06/2026 coded as quarterly documents section C0500 BIMS (Brief Interview for Mental Status) as 03 - severe cognitive impairment. Section GG of the same MDS documents Functional…

  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 before2026-03-27 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide 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 obtain daily weights per physicians orders for a resident with a history of weight loss for 1 of 4 residents (R5) reviewed for weight loss in the sample of 34.Findings include:R5's Face Sheet documented an admission Date of 3/10/23 with diagnoses to include Dementia, Epilepsy, and Chronic Kidney Disease. R5's Minimum Data Set, dated [DATE] documented R5 has moderate deficits in cognition.R5's Care Plan dated 2/12/26 documented a problem area, Resident has had a weight loss of 14% (percent) in 6 months and 2.7% in 1 month. R5's March 2026 Physicians Orders documented an order for daily weights with a start date of 3/19/26.R5's March 3/1/26-3/27/26 Vital Report documented that R5 weighed 156 pounds on 3/2/26 and 169.4 pounds on 3/27/26. These were the only 2 weights charted.On 03/26/2026 at 1:57 PM, V11 (Registered Dietician) stated R5's oral intake has improved within the past month and her weight is picking up and has stabilized. V11 stated 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 · D2026-03-27 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such 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 interview and record review, the facility failed to weigh a dialysis resident daily per physicians orders and to maintain regular communication with the dialysis center about post dialysis weights for one resident of one resident (R3) reviewed for dialysis in the sample of 34.Findings include:R3's Face Sheet documented an admission Date of 12/6/24 and listed Diagnoses including End Stage Renal Failure, Cirrhosis of the Liver, and Diabetes Type 2.R3's Minimum Data Set, dated [DATE] documented that R3 has no deficits in cognition and receives hemodialysis. R3's Care Plan dated 2/24/26 documented a problem area, I am at risk for complications due to End Stage Renal Disease & Hemodialysis therapy. I go to (company name) Dialysis on Tuesday, Thursday, and Saturday. I have history of right nephrectomy. I frequently refuse Lactulose. I am not receptive to education.R3's March 2026 Physicians Orders documented an order for daily weights with a start date of 12/6/24, and an order to obtain post dialysis weights…

  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 before2026-03-27 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow infection control practices for 2 (R10 and R96) of 6 residents reviewed for infection control in the sample of 34. The findings include:1. R96's face sheet documented that R96 was admitted to the facility on [DATE]. Diagnoses listed include metabolic encephalopathy, type 2 diabetes mellitus, acute kidney failure, chronic kidney disease stage 4, non-pressure chronic ulcer of other part of left foot, atherosclerotic heart disease, depression, essential hypertension, and hyperlipidemia. R96's Physicians order for blood glucose dated 01/22/2026, documents an order for blood glucose to be taken prior to giving sliding scale insulin before meals. On 03/25/2026 at 7:46 AM, V10 (Licensed Practical Nurse) opened the medication cart and removed the blood glucose monitor device placing it on top of the medication cart. V10 then put gloves on, walked over to R96. V10 then cleaned R96's left first finger with an alcohol prep pad. V10 then used…

  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
• Potential for harm · Dcited before2025-10-09 · 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 interview, observation, and record review, the facility failed to properly secure a resident's wheelchair into the facility van for 1 of 3 residents (R1) reviewed for accidents in the sample of 3.This past non-compliance occurred between 9/19/25 and 9/20/25.The findings include:R1's Face Sheet documented an admission Date of 3/1/25 and listed Diagnoses including COPD (Chronic Obstructive Pulmonary Disease), Atrial Fibrillation, Rheumatoid Arthritis, and Hypertension. A Minimum Data Set, dated [DATE] documented that R1 has moderate deficits in cognition, has impaired range of motion to both lower extremities, and requires the use of a wheelchair. R1's Care Plan with a start date of 4/15/25 and a review date of 9/23/25 documented a problem area, I am prescribed anticoagulant medication.R1's Event Report documents an event date and time of 9/19/25 at 1:27pm, description of fall, and a location of facility vehicle. Under Conclusion of root cause documents Resident's wheelchair tipped to the right side but…

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

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · Fcited before2025-02-21 · tag F0880 — failed to prevent and control infections — widespread
  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 utilize PPE (Personal Protective Equipment) per CDC (Centers for Disease Control) guidelines when coming in contact with Covid positive residents. This has the potential to affect all 74 residents living at the facility. Findings include: On 2/18/25 at 1:00pm, signage to the facility's front entrance read, Community respiratory illness activity is high. Masks are strongly recommended to protect our residents. Notice per IDPH (Illinois Department of Public Health) regulations notice is hereby given that a positive Covid test result has been confirmed (in a) resident. R3's Face sheet documented an admission Date of 1/10/25 and listed diagnoses including Left Fibula Fracture and Hypertension. R3's Physicians Orders for February 2025 documented a 2/13/25 order for droplet/contact isolation due to a positive Covid test result. R12's Face Sheet documented an admission Date of 1/31/25 and listed diagnoses including Parkinson's Disease and Dementia. R12's February 2025 Physicians Orders documented a 2/13/25 order for…

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

  Infection Control 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.

Fines & penalties

$126,387 in federal fines across 4 penalties. 2 Medicare payment denials on record.

• $56,024 — penalty dated 2025-01-24
• $14,050 — penalty dated 2024-08-27
• $39,767 — penalty dated 2024-03-01
• $16,546 — penalty dated 2024-01-18
• Medicare payment denial — starting 2025-02-15 for 14 days
• Medicare payment denial — starting 2024-03-28 for 1 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PALLADIAN HEALTHCARE — 6 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 →

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

CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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 $396K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL