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Central Baptist Village

4747 North Canfield Avenue, Norridge, IL 60656 · Non profit - Church related · 116 certified beds · (708) 583-8500 Medicare & Medicaid certified

Call the home — (708) 583-8500 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 21 lower-level deficiencies on record (see below)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
Worth asking about
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4900 N Cumberland Ave · (708) 456-1600 · Call to confirm hours
Pharmacy
Walgreens0.7 mi
5753 N Canfield Ave · (773) 631-2851 · Call to confirm hours
Grocery
5628 N Redwood Dr · (908) 531-1511 · Call to confirm hours
Park
5430 N Olcott Ave · 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 3 of 5
Long-stay residentspeople who live here 3 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 improved from 4 to 5 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 rating5★
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 increased18.4%13.4%15.4%worse
Long-stay residents who lose too much weight7.8%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.9%0.9%better
Long-stay residents with a urinary tract infection2.6%1.5%2.0%worse
Long-stay residents with depressive symptoms1.8%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.7%3.1%3.3%better
Long-stay residents whose ability to walk worsened27.7%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication14.2%18.3%18.9%better
Long-stay residents given the seasonal flu vaccine98.0%91.8%95.3%typical
Long-stay residents with pressure ulcers5.7%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control23.7%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.0%21.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.5%2.2%1.4%typical
Short-stay residents given the seasonal flu vaccine83.1%63.1%79.4%typical
Short-stay residents rehospitalized after admission22.2%26.1%22.6%typical
Short-stay residents with an outpatient ER visit10.6%13.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.272.021.67worse
Long-stay outpatient ER visits per 1,000 resident days0.682.221.80better

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.

59.2% 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 96 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.2%U.S. median 51.5%
Got home and stayed home
8.9%U.S. median 10.7%
Went back to hospital
41.1%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 41.1% 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 90 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 0.22 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNF59.2%CMS range 47.9–68.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.9%CMS range 6.5–13.510.7%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 discharge41.1%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 discharge40.0%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 discharge32.2%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 identified86.7%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 hospitalization5.9%CMS range 3.4–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.961.02Oct 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

1.03
RN hours/ resident / day
0.66
LPN hours/ resident / day
2.87
Aide hours/ resident / day
4.56
Total nurse hours/ resident / day
0.57
RN hoursweekends
42.0%
Total nursing turnover
36.0%
RN turnover

How full it usually is: this home is certified for 116 beds and averages 86.1 residents a day — about 74% occupied, or roughly 30 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 4.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.92 hrs/resident/day on weekends vs 4.82 on weekdays — 19% thinner on weekends. RN hours go from 1.21 to 0.57 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% 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

7
deficiencies at the latest standard inspection (2025-08-08)
5
at the previous standard inspection (2024-08-15)

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.

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.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · D2026-06-15 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notice of the facility's bed-hold policy to the resident and/or resident representative at the time of transfer to the hospital or within 24 hours of transfer for two (R1, R2) of three residents reviewed for hospital transfers; the facility also failed to complete a discharge summary/recapitulation of stay when R1 and R2 did not return to the facility and were discharged from the facility.Findings include:R1's face sheet documented R1 was Medicare Part A on 04/30/26. R1 was transferred to a local hospital on [DATE]. A physician progress note dated 04/30/26 documented, Patient being transferred to the acute hospital for evaluation of abdominal abscess as the abdomen is getting bigger and hardening. She has stable pain in the abdomen without worsening. Review of R1's clinical record revealed no documented bed-hold notice was provided to R1 and/or R1's representative at the time of transfer to the hospital or within 24 hours of transfer.…

    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 before2025-08-08 · tag F0880 — failed to prevent and control infections — pattern
    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 perform hand hygiene when providing resident care and failed to ensure staff adhered to Enhanced Barrier Precautions. This applies to 6 of 6 (R3, R4, R6, R44, R81, and R8) residents reviewed for infection control in a sample of 25. Findings include: 1. [DATE] at 11:00 AM, V14 (CNA-Certified Nursing Assistant) and V18 (CNA) provided morning care to R6. R6 had a supra-pubic catheter draining urine into the urine bag. V14 emptied the urine from the urine drainage bag into a urinal. After emptying, V14 did not clean the spout and replaced it in its slot. After discarding the urine into the toilet, V14 removed his gloves, did not perform hand hygiene and put on another pair of gloves. V14 opened R6's soiled diaper, and while wearing the same gloves, reached into his pockets and pulled out a roll of plastic bags, tore off two bags, and placed the roll back in his pockets. V14 turned R6 to her right side, held by V18 (CNA), and wiped off stool…

    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 · D2025-08-08 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    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 assist residents with feeding in a dignified manner.This applies to 3 of 3 residents (R56, R83, and R79) reviewed for dignity in a sample of 25. Findings include:1. On 8/05/2025 at 12:50 PM, V7 (Registered Nurse/RN) was assisting R56 with her meal in the dining room. V7 mixed R56's served pureed entree food items together. V7 proceeded to feed R56 her mixed pureed meal.On 8/07/2025 at 8:50 AM, R56 was in bed. V8 (RN) was standing over R56 and assisting her with her meal. V8 mixed R56's served pureed entree food items together. V8 said R56 was served eggs, hash brown, and an unknown brownish food item. V8 said R56 consumed 50 % of the main entree.R56's care plan reviewed on 8/07/2025, said R56 was cognitively impaired and required physical staff assistance with eating. R56's care plan did not include mixing all R56's different pureed foods together for meals.2. On 8/05/2025 at 12:20 PM, R83 was in the dining room for lunch. R83 was exhibiting increased anxiety. R83 was attempting to grab her pureed meal items.…

    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 · D2025-08-08 · 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

    Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) cares for residents who require assistance with their ADLs.This applies to 2 out of 2 residents (R5 and R64) reviewed ADLs in a sample of 25.The findings include:Findings include: 1. On 8/05/2025 at 10:58 AM, R64 was sitting in her wheelchair in the hallway right outside of her room. Her call light was going off. R64 was observed crying. R64, stated, I have to go to the bathroom, but my roommate is in our bathroom. R64 stated she pressed the call light and is waiting for staff to clean her up but she herself has been waiting a long time to be taken to the bathroom. R64 stated It's been a while I really have to go .I can't wait any longer .someone came and then left .I think I'm going in my pants. At 11:35 AM, R64 was in the day room. Her hair was greasy and not combed. She had hair strands above her lip. R64 said she was blind and wanted the whiskers above her lip shaved. R64 stated staff didn't comb her hair today and staff didn't brush her teeth either when they got…

    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 · D2025-08-08 · 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

    Based on observation, interview, and record review, the facility failed to apply left and right palm protectors as ordered by physician.This applies to 1 resident (R76) reviewed for range of motion and contractures in a sample of 25.The findings include:On 8/6/25 at 11:41 AM R76 was observed sitting in large activity room with no palm protector on her right hand. Her right hand was closed with fingers extended against palm. On 8/6/25 at 11:46 AM, V8 (LPN/Licensed Practical Nurse) was asked if R76 had an order for palm protectors. V8 said he was not sure and V7 (RN/Registered Nurse) was R76's nurse. On 8/6/25 at 11:49 AM V7 was observed removing R76 from the dining room. V7 (RN) said the CNA (Certified Nurse Assistant) forgot to put R76's palm protectors on this morning. On 8/6/25 at 11:58 AM, V7 wheeled R76 back into dining room for lunch and pointed out to surveyor that she put both R76's left and right palm protector on. Both R76's left and right palm protectors remained on throughout lunch service. On 8/6/25 at 2:19 PM, V12 (CNA) said she was taking care of R76, and it was her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-08 · 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 observation, interview, and record review, the facility failed to provide catheter care in a manner to prevent urinary tract infections for a resident with an indwelling urinary catheter. This applies to 1 resident (R8) reviewed for urinary catheters in a sample of 25.The findings include:R8's Face Sheet shows the following diagnoses: flaccid neuropathic bladder, personal history of urinary tract infections, retention of urine, and dementia. R8's POS (Physician Order Sheet) showed a 3/21/2024 order of catheter care (clean catheter with soap and water. Start at entry site. Clean catheter every incontinence episode).On 8/6/25 at 12:24 PM, R8 was in her wheelchair in the dining room. R8's urinary catheter drainage bag was in a privacy bag under her wheelchair. The privacy bag was dragging on the floor and had a dried-up white stain on it across the entire width of the bag, about halfway up the bag. On 8/7/25 at 9:50 AM, R8's catheter care was performed by V13 (CNA/Certified Nurse Assistant). V13 emptied R8's drainage bag. R8's urinary catheter privacy bag was attached to her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-08 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to aspirate gastric contents to check the placement of a resident's gastrostomy tube (GT). This applies to 1 of 1 (R3) residents reviewed for GT care in a sample of 25.Findings include:On 8/5/25 at 1:40 PM, V17 RN (Registered Nurse) used a large syringe and pushed 10-15 ml of air through R3's GT and auscultated her abdomen to check the placement of the tubing.On 8/6/25 at 11:23 AM, V10 (RN) used a large syringe and pushed 15 ml air into the GT and auscultated R3's abdomen with a stethoscope. V10 stated she heard the gurgling sound of the air being pushed in. V10 then pushed 160 ml water with the syringe into the GT as per orders. V10 stated the facility had taught them to check for GT placement in this manner.R3's 4/24/2025 care plan showed, check for tube placement and gastric contents prior to beginning feeding. R3's physician orders showed a 4/6/25 order to check G-tube placement before feeding and medication administration every shift.On 8/7/25 at 12:30 PM V2 (DON-Director of Nursing) stated facility has not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-08 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 administer medications as ordered. There were 30 opportunities with 3 errors resulting in a 10% error rate. This applies to 1 of 5 residents (R17) observed in medication pass.The findings include:Findings include:On 08/06/2025 at 9:20 AM, V10 (Registered Nurse/RN) prepared R17's 8:00 AM scheduled medications. R17's prepared medications did not include tablets of spironolactone 25 mg (milligram) tablet, vitamin B12 1000 mcg (microgram) tablet, or the furosemide 40 mg tablet. V10 said she forgot to include the medications as ordered. On 08/07/2025 11:50 AM, V4 (Assistant Director of Nursing) said nurses received medication administration training routinely to ensure safe administration of medications. V4 said V10 should have checked R17's EMAR (Electronic Medication Administration Record) to ensure all scheduled medications were prepared and administered as ordered. On 08/07/2025 11:25 AM, V2 (Director of Nursing/DON) said nurses were expected to check medication rights prior to administering medications 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-02 · 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 the interviews and record reviews, the facility failed to provide the required staff assistance for bed mobility and ambulation for dependent residents as per the MDS (Minimum Data Set) assessment. This applies to 2 of the 3 residents (R1 and R2) reviewed for resident falls and injuries in a sample of 3. The Findings Include: 1. R1 is an [AGE] year-old female admitted on the dementia floor on 8/18/22 with an admitting diagnosis, including vascular dementia and multiple sclerosis. On 12/31/24 at 9:25 AM, R1 was observed in her bed and was unable to move her lower extremities except wiggling toes. On 12/31/24 at 9:25 AM, R1 stated, I had a fall to the right side of my bed. My leg didn't move the way I want to. I don't remember what my CNA was doing at that time. A review of R1's fall risk assessment dated [DATE] document that R1 is high risk for fall. A review of the R1's ADL (Activities of Daily Living) care plan document interventions including the resident requires physical assistance by staff to turn…

    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 · Fcited before2024-08-15 · 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 interview and record review, the facility failed to document and track HCP (Health Care Providers) covid test results during a covid outbreak in accordance with their policy. This applies to all 102 residents who reside in the facility. The findings include: The form 671 completed on August 12, 2024, showed a facility census of 102. Upon annual survey entrance conference on August 12, 2024, at 9:30 AM, V1 (Administrator) stated there are 16 covid positive residents on the second floor. On August 14, 2024, at 10:17 AM, V3 (IP-Infection Preventionist)) stated R66 tested positive for covid on August 8, 2024, and was tested by a nurse on the second-floor unit due to displaying symptoms of covid. V3 was unable to provide testing results of HCP (Health Care Providers) who were exposed to R66. V3 stated in response to R66 positive test results, all the residents on the second floor were tested for covid, but HCPs tested themselves and V3 did not have any documentation to validate HCP testing. V3 provided a list of staff who had tested positive for covid, titled Staff Syndromic…

    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 11 citations
  • Potential for harm · E2024-08-15 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to serve portions of Garlic Herb Roasted Pork Tenderloin to residents receiving mechanically altered diets as planned on the approved facility menu. This applies to 5 of 5 residents (R1, R41, R52, R62, and R87) reviewed for portion sizes. The findings include: Resident Summary Report, printed August 12, 2024, shows R1, R41, R52, R62, and R87 were to all be served ground meats at meals. Spread sheet, dated August 12, 2024, shows residents with regular diets were to be served 4 ounces of Garlic Herb Pork Tenderloin and residents receiving Ground Meat or Mechanical Soft diets were to be served ground garlic herb pork using a 4 oz spoodle spoon. On August 12, 2024 at 12:07 PM on the first floor during lunch service, V17 (Food Service Worker) stated he was using a three ounce scoop to serve portions of ground Garlic Herb Roasted Pork Tenderloin to residents. V17 stated he was concerned he did not have enough ground pork product for lunch service to residents, so he changed the serving size from 4 ounces to 3 ounces 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-08-15 · tag F0806 — failed to honor food preferences — pattern
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    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 offer/provide residents food substitutions equivalent in nutritive value to the originally planned/served menu items. This applies to 4 of 4 residents (R54, R57, R83, and R96) reviewed for food substitutions. The findings include: On August 12, 2024, V17 (Food Service Worker) plated the following food items on plates for residents during meal service: 1. R54 received a half sandwich (1 piece of bread cut in half) with no cheese and 2 half slices of thinly sliced ham between the half pieces of bread. R54's tray ticket showed R54 was to receive a regular/general diet with no further modifications. 2. R96 received a half sandwich (1 piece of bread cut in half) with no cheese and 2 half slices of thinly sliced ham between the half pieces of bread. R96's tray ticket showed R96 was to receive a regular/general diet with finger foods and small portions. 3. R57 received a half sandwich (1 piece of bread cut in half) with a very thin layer of peanut butter and jelly between the half pieces of bread. R57's lunch tray…

    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 · D2024-08-15 · 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

    Based on observation, interview, and record review the facility failed to follow a resident's plan of care to prevent and treat the development of facility-acquired pressure wounds for a resident at high risk for pressure wounds. This applies to 1 of 4 residents (R25) reviewed for facility-acquired pressure injuries in the sample 21. The findings include: Face sheet, dated August 14, 2024, shows R25's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting her right non-dominant side, congestive heart failure, vascular dementia, sacroiliitis, spinal stenosis, muscle weakness, venous insufficiency, and need for assistance with personal care. R25's historical skin integrity care plans showed R25 was identified to have a potential for skin impairment related to decreased mobility and incontinence on September 16, 2024. On July 16, 2024, R25 was identified to have developed a new facility-acquired a stage 3 pressure wound on her sacrum related to decreased mobility and incontinence. Intervention, initiated July 16, 2024 and revised on August 12, 2024,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-15 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to follow their policy to administer medications as ordered by the physician. There were 33 opportunities with 3 medication administration errors resulting in a 9.09% medication error rate. This applies to 2 of 4 residents (R65, R73) reviewed for medication administration in the sample of 21. The findings include: 1. On August 13, 2024, at 8:59 AM, V14 (MDS/Minimum Data Set Coordinator) prepared R65's morning medications, including one tablet folic acid 800 mcg (micrograms), one tablet gabapentin 300 mg (milligrams), one tablet losartan/hydrochlorothiazide 50/12.5 mg, one tablet metoprolol tartrate 50 mg, one tablet potassium chloride 20 mEq (milliequivalents), one tablet PreserVision eye vitamin, one tablet vitamin B12 500 mcg, and one tablet vitamin D3 50 mcg for a total of eight tablets. V14 also prepared one capful of polyethylene glycol mixed in a cup of water. On August 13, 2024, at 9:08 AM, V14 said she was ready to administer R65's medications and counted nine tablets to be administered to R65. V14 was…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-07 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 food was prepared in a manner to prevent cross-contamination for 4 of 4 residents (R15, R35, R83 and R88) reviewed for pureed foods in the sample of 21, and 4 residents outside the sample (R5, R54, R74, and R90). The findings include: On 9/06/23 at 9:02 AM, V10 (puree cook) was making the pureed foods for the lunch meal. V10 was putting 14 chicken breasts in the food processor to puree them for the lunch meal. While picking up some of the chicken breasts, 2 of the chicken breasts touched V10's visibly soiled apron. V10 put the chicken breasts that touched her soiled apron into the food processor with the other chicken breasts, added 2 cups of chicken broth, and turned on the food processor to puree the chicken. V10 added thickener to the food processor and turned it back on. V10 took the lid back off the food processor and put her gloved hand, (that she had used to move the pan the chicken was in, turn the food processor on and off several times, grab the handle of the pan containing chicken broth, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · 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 ensure privacy was provided for a resident during care for 1 of 1 resident (R47) reviewed for privacy in the sample of 21. The findings include: On 9/5/23 at 11:09 AM, R47 was sitting in her wheelchair in her room waiting to go to the bathroom. V3 CNA (Certified Nursing Assistant) came into R47's room to take her to the toilet. V3 left the door open to R47's room. V3 wheeled R47 into the bathroom, had R47 stand at the grab bar while she pulled down R47's pants and incontinence brief. R47 was incontinent of urine and feces. R47 was assisted to sit on the toilet. The bathroom door was left open while R47 was on the toilet. V3 left the bathroom to get a pad and incontinence brief for R47 and the bathroom door remained open. People were walking in the hallway while R47's bedroom and bathroom door were both open and R47 was on the toilet. V3 went back into R47's bathroom, provided incontinence care, put an incontinence brief, and pulled R47's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to develop a care plan in a timely manner to address a pressure injury for 1 of 3 residents (R44) reviewed for pressure in the sample of 21. The findings include: On 9/5/23 at 11:22 AM, R44 was sitting in the activity room in her wheelchair. R44 had pressure-relieving boots on both of her feet. R44's Skin/Wound Note dated 5/15/23 showed she had an unstageable DTI (deep tissue injury) to her left heel. The note showed the wound was an intact blister measuring 3.1 cm (centimeters) by 4.6 cm that was dark blue in color. R44's Skin/Wound Note dated 9/1/23 showed R44 still had the pressure injury on that date (over three months later). R44's care plans were reviewed, showing the care plan for her existing pressure injury was initiated on 9/5/23 (the same day the facility's annual survey had begun). A care plan, with a revision date of 7/26/23, was in place showing R44 had the potential for impairment to the integrity of her skin related to incontinence, however, the care plan did not mention her existing pressure…

    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 · Dcited before2023-09-07 · 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 provide a safe transfer for 1 of 1 resident (R107) reviewed for safety and supervision in the sample of 21. The findings include: On 9/5/23 at 10:56 AM, V3 CNA (Certified Nursing Assistant) took R107 in her wheelchair to her bathroom door. V3 had a gait belt around her own waist but did not place the gait belt on R107. V3 assisted R107 to standing by pulling on the back of the resident's pants in an upward motion. V3 told R107 to hold onto the grab bar in the bathroom. R107 was having trouble turning in the bathroom and V3 hooked her arm under R107's arm to turn her. V3 pulled R107's pants and incontinence brief down that was soiled with diarrhea. R107 then plopped down onto the toilet seat. After R107 was toileted, V3 hooked her arm under the resident's arm to have her stand and hold onto the grab bar. V3 then cleaned the resident's buttocks, pulled up a clean incontinence brief and her pants. V3 turned R107 and had her sit in her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-07 · 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 observation, interview, and record review the facility failed to ensure a residents indwelling urinary catheter drainage bag was not on the floor for 1 of 2 residents (R50) reviewed for catheters in the sample of 21. The findings include: On 9/5/23 at 1:44 PM, R50 was lying on his back in bed with his bed in the lowest position. R50 had an indwelling urinary catheter, and the drainage bag was attached to the frame of his bed under his mattress The drainage bag was folded over under the bed and partially on the floor. On 9/5/23 at 1:48 PM, V4 RN (Registered Nurse) went into R50's room, looked at his catheter drainage bag, and stated it should not be on the floor because it could become contaminated. On 9/5/23 V2 DON (Director of Nursing) was not available for the survey. V2 was off for the week and could not be interviewed for privacy/dignity concerns. R5 RN (Registered Nurse) was available in the DON's absence. On 9/7/23 at 9:35 AM, V5 RN (Infection Control Preventionist) stated indwelling urinary catheter drainage bags should not touch the floor for infection control…

    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 · D2023-09-07 · 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 observation, interview, and record review, the facility failed to ensure weekly weights were obtained for 1 of 8 residents (R44) reviewed for nutrition in the sample of 21. The findings include: R44's admission Record, printed by the facility on 9/7/23, showed she had diagnoses including moderate dementia with behavioral disturbance, anemia, generalized anxiety disorder, psychosis, major depressive disorder, osteoarthritis, and an unstageable pressure injury to her left heel. On 9/5/23 at 12:27 PM, R44 was sitting in her wheelchair, by the entrance to the dining room on the memory care unit. R44 was being assisted and encouraged during the lunch meal by staff. R44 was drinking her juice and coffee. R44 ate less than 25% of the lunch meal. R44's facility assessment dated [DATE] showed she had moderately impaired cognitive skills for daily decision making. The assessment showed R44 had short-term and long-term memory problems and requires extensive assist of one staff member for eating. The assessment…

    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 before2023-09-07 · 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 prevent cross contamination of resident contact surfaces by not removing gloves and washing hands after providing incontinence care for 3 of 3 residents (R107, R47, & R35) reviewed for infection control in the sample of 21. The findings include: 1. On 9/5/23 at 10:56 AM, V3 CNA (Certified Nursing Assistant) took R107 to the bathroom to be toileted. V3 pushed R107 in her wheelchair into the bathroom. V3 had gloves on and assisted R107 to stand. V3 told R107 to hold onto the grab bar. V3 pulled R107's pants and incontinence brief down. V3 removed R107's incontinence brief that was soiled with diarrhea. V3 had R107 sit on the toilet. V3 threw the soiled incontinence brief away, removed her gloves, and washed her hands. V3 went into R107's room and came back with an incontinence brief and disposable wipes. V3 put clean gloves on and put the clean incontinence brief around R107's legs above her pulled down pants. V3 assisted R107 to stand 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.

    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.

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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
ANDREWS, DANIELIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 04/03/2023
COBAN, MARYIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2008
DUNNE BERNARDI, JUDITHIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2003
GUSTAFSON, RICHARDIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 03/16/2015
JOHNSON, CAROLYNIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 03/01/2013
LEEPER, CONNIEIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2006
MCGOVERN, RAYMONDIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/1996
SALVADOR, CARLOIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 01/01/2009
SCHILL, JOSEPHIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 03/21/2022
SIMANIS, GUNDARSIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/30/2023
WHITESELL, ROBERTIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 06/21/2021
WITT, DANIELIndividualCORPORATE DIRECTOR; TRUSTEE OF THE SNFsince 03/18/2019
WOLTER, MARLENEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/05/2008
DALTON, MARYIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/05/2022
LACROIX, ANNA-LIISAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/11/2023
ALTMAN, LORIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/23/2009
KOO, KEVINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/02/2021
RAGSDALE, JONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/23/2023

CMS files one row per role, so the 40 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$19.2M
Net patient revenuemost recent cost report
-15.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 21%Medicare 5%Other / private 74%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$480per resident / day
operating cost
$14,585per month
≈ monthly operating cost
$417per 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 145853. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-08, 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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