Smith Crossing

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.

71.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 810 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 56.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 424 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 0.54 therapist hours per resident per day in 2026Q1 — more than 84% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 92 beds and averages 81.4 residents a day — about 88% occupied, or roughly 11 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 5.43 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.29 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.24 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 5.07 hrs/resident/day on weekends vs 5.58 on weekdays — 9% thinner on weekends. RN hours go from 1.43 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

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

Inspection trend

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.

32 citations, most serious first. The 14 most serious are shown; the remaining 18 are one tap away and print in full.

• Actual harm · Gcited before2025-06-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent the development of an unstageable pressure ulcer for a resident at moderate risk for skin breakdown. This failure led to a resident requiring skin grafting. This applies to 1 of 4 residents (R59) reviewed for pressure ulcers in a sample of 21. The findings include: On 06/17/25 at 10:14 AM, a bright-red, quarter-sized, open wound was present on R59's sacrum. R59 had an indwelling urinary catheter. R59's electronic health records showed that he was admitted on [DATE], with R59's first pressure ulcer risk assessment completed on 3/4/2025. The assessment showed R59 was at moderate risk for skin breakdown. On 06/17/25 at 10:14 AM, V27 (Wound Nurse) stated that R59 had a stage 4 pressure ulcer. V27 said that R59's stage 4 pressure ulcer started as MASD (Moisture Associated Skin Damage) to R59's sacrum and the MASD could have been avoided by providing incontinence care and frequent repositioning. V7 provided R59's sacral wound…

  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 before2025-04-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that a cognitively impaired resident received treatment and care in accordance with professional standards of practice for 1 of 4 residents (R2) reviewed for nursing care and services. This failure resulted in staff pulling on R2's contracted arm while turning resident in bed that caused R2 to experience moderate to severe pain to her left arm and was subsequently diagnosed with a fracture to the left humeral head (upper arm). Findings include: R2's face sheet showed an initial admission date on 07/12/2021 with a past medical history not limited to: left humerus fracture (04/18/2025), dementia, spinal stenosis, heart failure, type 2 diabetes, hypertension and transient ischemic attack and cerebral infarction. R2's Minimum Data Set (MDS) dated [DATE] under Section C for cognitive patterns showed a Brief Interview for Mental Status (BIMS) score of 02/15 that indicates severe cognitive impairment. Section GG documented under functional limitation…

  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 before2025-04-30 · 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, interviews, and record review, the facility failed to implement effective fall interventions to minimize the risk of falls, failed to ensure current fall interventions were in place for a resident at risk for falls, and failed to provide adequate supervision to prevent repeated falls with or without significant injury for 3 of 4 residents (R1, R3, R4) reviewed for accidents and supervision in a sample size of 4. This failure resulted in R4, who is a high fall risk with repeated falls, being observed without current fall preventative interventions in place; and resulted in R1 and R3 who had repeated falls and subsequently were emergently transferred to the hospital after a fall incident for treatment of a cervical neck fracture and facial abrasion (R1) and closure of a head laceration with staples (R3). Findings include: Review of facility fall log for [DATE] and February through [DATE] showed the following: R1: with fall incidents on [DATE], [DATE] and [DATE]. R3 with fall incidents on…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2023-08-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 safe transfer assistance. This applies to 5 of 9 residents (R1-R5) reviewed for transfers in a sample of 9. This failure resulted in R1 incurring a fracture of the right femur and R3 incurring a fracture of her right humerus. Findings include: 1. R1's Face Sheet dated 8/9/2023 documents R1 as a [AGE] year old with diagnoses to include a right periprosthetic fracture around an artificial knee joint, Vascular Dementia and History of a Stroke. On 8/4/2023 12:15 PM V28 (R1's Daughter) stated she was at the facility on 7/9/2023. After lunch R1 had to use the bathroom and was transferred using a stand assist mechanical lift by V9 (Former Nursing Assistant). V28 stated V9 was the only staff member present completing R1's transfer and V9 did not have R1's legs strapped into the machine properly. V28 stated, typically the girls strap her legs in, and she was not secured against the (leg) plate like she usually is which left too much give.…

  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 before2026-03-12 · tag F0694 — isolated
  Provide for the safe, appropriate administration of IV fluids for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure that a Licensed Practical Nurse (LPN) had training/certification to infuse an intravenous (IV) medication. This applies to 1 of 1 resident (R1) reviewed for IV medication administration in the sample of 3. Findings include:R1's EMR (Electronic Medical Record) shows R1 has diagnoses including urinary tract infection, sepsis, difficulty walking, unspecified skin changes, chronic congestive heart failure, kidney failure, unspecified organism, vascular dementia, type 2 diabetes Mellitus with other circulatory complications. R1 had the following physician's order from February 10, 2026, through February 14, 2026: Vancomycin HCI intravenous solution, use 750 MG (milligrams) intravenously every 18 hours for anti-infective (IV piggyback).On March 12, 2026, at 3:11 PM, V5 (LPN, Licensed Practical Nurse) stated she is not certified to give intravenous antibiotics, however she gave some to R1 about a month ago. V5 also stated she is going to get the training for it but at present she is not certified for infusing intravenous…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-18 · tag F0628 — pattern
  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 2. R13's progress notes show the following: On 12/30/24 at 9:14 PM at 6 PM, (R13) observed supine on floor near window. Limb shortening noted to LLE (Left Lower Extremity). (R13) complained of pain to RLE (Right Lower Extremity), but unable to rate pain using number scale. This nurse called 911 and notified dispatch of unwitnessed fall. Called Fire Department. EMT (Emergency Medical Technician) arrived. (R13) sent to hospital emergency room. On 12/30/24 at 11:14 PM, (R13) admitted to ICU (Intensive Care Unit) with a diagnosis of subdural hematoma. On 12/31/24 at 7:56 PM, (R13) returned from hospital with POA (Power of Attorney) at bedside via stretcher with ambulance services. On 3/21/25 at 10:12 PM, Writer was called to (R13)'s room by the CNA (Certified Nursing Assistant). Writer observed (R13) sitting on the side of the bed on the floor. (R13) was bleeding from her head. Writer then called 911 and POA and other daughter. 911 came and got resident. On 3/22/25 at 6:36 AM, (R13) returned from the emergency…

  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 before2025-06-18 · 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

  4. On 6/16/25, at 9:30 AM, R330 was resting on her bed and just had a bowel movement on the bed pan. V22 (CNA) provided peri-care with the assistance of V21 (Nurse). V22 cleaned R330's back perineum, removed the bed pan, emptied the stool into the toilet, returned to R330, and continued to clean R330's frontal perineum. V21 and V22 applied a clean incontinence brief and assisted to reposition R330. V22 changed her gloves in between all these tasks without performing hand hygiene. On 6/17/25, at 11:01 AM, V2 (DON) stated the staff must perform hand hygiene and change gloves in between tasks, such as dirty to clean tasks, to prevent cross contamination and spread of infection. Facility's Policy and Procedure for Hand Hygiene dated December 2024, shows: Policy: All staff will perform proper hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene…

  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 · D2025-06-18 · 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

  Based on observation, interview, and record review, the facility failed to provide a dignified dining experience. This applies to 1 resident (R26) reviewed for dignity in a sample of 21. The findings include: On 6/15/25 at 12:10 PM, in the back table, there were four residents. R21, R40, and R42 were eating their lunch, while R26 watched them eating. R26 did not get her tray at the same time as R21, R40, and R42. R26 then dozed off in front of other three residents. It was not only until at 12:34 PM, that V12 (Dietary Aide) delivered the lunch tray which consisted of chicken, pasta, sauce, and pureed veggies. R26 was unable to be interviewed. R26's MDS (Minimum Data Set) dated 4/22/25 shows that she is severely cognitively impaired. It also shows that she needs set up assistance with eating. R26's care plan dated (6/12/25) shows she is at risk for nutrition decline. On 6/16/25 at 1:53 PM, V14 (Director of Dining Services) said, Yes, theoretically residents at the same table should be served at the same time because it's a dignity issue. Facility's policy titled Resident Meal…

  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 · D2025-06-18 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's medical records were in agreement with his wishes for his advance directives. This applies to 1 of 6 residents reviewed for advance directives in a sample of 21. The findings include: On [DATE] at 09:18 AM, R54's Electronic Medical Record (EMR) did not contain a POLST form (Physician Order for Life-Sustaining Treatment) that showed he did not want CPR (cardio-pulmponary resuscitation). On [DATE] at 02:40 PM, R54's chart at the nurse's station contained an advance directive form that showed DNR (Do Not Resuscitate), dated and signed on [DATE] by R54. R54's Face Sheet showed he was a Full Code. On [DATE] at 10:06 AM, R54 said that no one from the facility asked him what his advance directives were. R54 said that he signed a DNR form 2 years ago, and he gave it to the facility, and that is his wish. R54's [DATE], MDS (Minimum Data Set) showed that R54's cognition is intact. On [DATE] at 4:55 PM, V11 (Resident Services Assistant) said…

  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 · D2025-06-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment. This applies to 2 of 2 residents (R2, R22) reviewed for environment in a sample of 21. The findings include: 1. On 6/15/25 at 10:40 AM, during initial tour, in R22's room, the base trim on the wall was more than halfway off and resting on the floor and it was extending into the doorway. On 6/16/25 at 10:20 AM, V19 (Director of Clinical Operations/RN-Registered Nurse) stated, EVS (Environmental Services), Housekeeping, and CNA (Certified Nursing Assistants) are supposed to do a work order to get it resolved. It's a team effort. If a CNA sees something like a loose baseboard, he or she is supposed to put in a work order. On 6/16/25 at 10:28 AM, V13 (Facilities Director) stated, whoever sees it first, be it nursing and/or housekeeping, they need to report it to me, so I can tell my staff to fix it. On 6/16/25 at 12:07 PM, R22 stated, Yes, I want that base board fixed. I don't know what happened. I don't want to fall over it. I've had a lot of falls here, but not because…

  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 · D2025-06-18 · 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) care to meet the needs of the residents. This applies to 3 of 3 residents (R54, R59 & R60) reviewed for ADLs care in a sample of 21. The findings include: 1. On 06/15/25 at 12:04 PM, R54's nails were long and jagged. R54 said that the last time his nails were cut were when he did them himself. R54 said that he would like for staff to assist him with nail care. On 06/17/25 at 10:05 AM, R54's nails remained long and jagged. R54's 5/14/24 MDS (Minimum Data Set) showed that R54 needs partial/moderate assistance from staff for personal hygiene. R54's 05/14/25 care plan showed a focus of ADL self-care performance deficit related to weakness, disease process, and limited mobility. 2. On 06/15/25 at 12:36 PM, R59, had long hair on his face and chin. R59 said that it had bed about 10 days since he has been shaved and the long hair on his face bothers him and he wants to be shaved. On 06/16/25 at 03:05 PM, R59's long hair on his face and chin was still present. On 06/17/25 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
• Potential for harm · D2025-06-18 · 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 peri-care in a manner that would prevent urinary tract infection, and failed to ensure that urinary catheter drainage bags are not touching the floor. This applies to 4 of 4 residents (R59, R128, R227, R330) reviewed for peri-care and catheter care in the sample of 21. The findings include: 1. Face sheet shows that R128 is 77 years-old who has multiple medical diagnoses including urinary retention. R128 has indwelling urinary catheter. On 6/15/25, at 11:10 AM, R128 was resting in her recliner with her urinary catheter bag resting on the floor. 2. R330's electronic medical record shows that R330 is 88 years-old. R330's restorative nursing program evaluation dated 6/16/25 shows that R330 has weakness and limited mobility. On 6/16/25, at 9:30 AM, V21 (Nurse) and V22 (Certified Nursing Assistant/CNA) rendered peri-care to R330 who had a bowel movement. They turned R330 on her side, then V22 proceeded to clean R330's rectum and buttocks. After cleaning R330's back perineum, they turned R330 on her back.…

  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 before2025-06-18 · 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 obtain orders for gastrostomy tube (g-tube) flushes. This applies to 2 of 2 residents (R64, R70) reviewed for gastrostomy tube in the sample of 21. The findings include: 1. On 6/16/25, at 12:53 PM, V16 (Nurse) administered Hydrocortisone and Midodrine tablets to R70 via g-tube. The medicines were crushed in separate cups and mixed with 30 ml of water. Prior to administration, V16 checked R70's g-tube placement by auscultating the abdomen and injecting 30 ml of air into the g-tube. V16 flushed the tube with 40 ml of water, prior to administration, in between the medications, and after administration. There was residue in both medicine cups, so V16 repeated the same cycle, mixing the residue with 30 ml of water and flushing the g-tube again with 40 ml of water prior to administration, in between medicine residue, and after administration. The water that was flushed or administered to R70 totaled to about 380 ml. When V16 completed the medication administration, V16 started setting up the g-tube feeding and…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-18 · 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 ensure that medications were administered as prescribed by the physician. There were 26 medication opportunities with 5 errors, resulting to 19.23% error rate. This applies to 2 of the 5 residents (R19, R70) reviewed for medication administration in the sample of 21. The findings include: 1. On 6/15/25, at 4:56 PM, V15 (Nurse) administered multiple oral medications, and one eye drop solution (Genteal eye drop) to R19. The medications include, Carvedilol, Ropinirole, Duloxetine, Ferrous Sulfate EC (Enteric Coated), Polyethylene Glycol. V15 crushed all these medications prior to administration. After V15 administered these medications, V15 stated that was all R19's scheduled medications at 5 PM. R19's Medication Administration Record (MAR), shows that there were other medications scheduled for 5:00 PM, these include Docusate Sodium (liquid), Voltaren External Gel, and Lidocaine Patch. These medications were not observed given to R19. However, V15 signed it as given. On 6/16/25 at 5:20 PM, V15 confirmed that…

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

  Pharmacy Service 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

$30,713 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $30,713 — penalty dated 2025-06-18
• Medicare payment denial — starting 2025-07-11 for 4 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.

Who owns this facility

CMS files one row per role, so the 33 rows in the source record cover these 13 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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

This home reported $2.4M paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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 2024. 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, FY2024). 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