Pleasant View Luther Home

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.

62.1% 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 214 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 73.8% 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 80 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 0.38 therapist hours per resident per day in 2026Q1 — more than 66% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 90 beds and averages 69.4 residents a day — about 77% occupied, or roughly 21 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 3.51 on weekdays — 9% thinner on weekends. RN hours go from 0.88 to 0.68 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

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

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.

36 citations, most serious first. The 15 most serious are shown; the remaining 21 are one tap away and print in full.

• Immediate jeopardy · J2024-12-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect a demented resident (R1) from sexual abuse by R2 with dementia and a known history of pacing, wandering, disrobing, and violence/aggression towards staff/others. This failure resulted in R2 placing his hand down R1's pants and performing repeated aggressive up and down sexual type motions. This failure resulted in R1 feeling frightened and requiring hospital examination where a minor tear near R1's vagina was noted. This failure has the potential to affect R1 and other dementia residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12/18/24 the facility remains out of compliance at Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: The Immediate Jeopardy began on 12/12/24 at 7:15pm when the facility failed to protect a demented resident (R1)…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-05-08 · 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 identify environmental hazards and implement fall prevention interventions for a resident who has a history of falls. This failure resulted in R1 tripping over a resident's wheelchair, falling and hitting his head on the floor sustaining a C1 (neck) fracture. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 5. Findings include: R1's Final Incident Report dated 4/14/25 shows (R1) is alert to self only. He requires the assistance of one caregiver to complete activities of daily living. He ambulates with his walker. On 4/10/25, (R1) finished breakfast in the dining room and began ambulating back to his room when he tripped and fell to the ground .(R1) complained of right shoulder pain and head pain. (R1) had a vomiting episode and superficial abrasion to right side of forehead he was transferred to the ER for evaluation. (R1) had imaging performed in the ER that showed a C1 fracture. R1's face sheet shows he is an…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-06-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident safety during assisted ambulation for one (R1) resident of four reviewed for falls in a sample of four. This failure resulted in R1 receiving a fractured femur followed by a decline in condition and subsequent death. Findings include: The facility's Falls Prevention and Post-Falls Management policy, dated [DATE], documents Policy: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other members of the multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. This policy also states Resident-Centered Approaches to Fall Risk Assessment: 5. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, Excessive motor activity, activities…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-31 · 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 interview, observation and record review, the facility failed to perform skin risk assessments, implement additional pressure relieving interventions after a change in condition, and identify a pressure ulcer prior to its status worsening to a Stage III for one of three residents (R9) reviewed for pressure ulcers in the sample of 38. This failure resulted in R9's pressure ulcer worseing without new interventions implemented. Findings Include: The facility's Pressure Injury Prevention policy (revised 01/10/24) documents the following: The community must ensure that : A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This policy also documents, Each resident is formally assessed for risk of developing pressure injuries using the Braden Scale completed upon admission, quarterly, significant changes, and after developing pressure injury. This same policy…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-01-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident safety during van transport for one (R1) of four residents reviewed for falls in a sample of three. This failure resulted in a 5th metacarpal fracture of R1's hand. Findings include: R1's current clinical record documents R1 is cognitively intact, and has diagnoses including generalized muscle weakness, low back pain, history of falls, and a left artificial hip joint (since 05/2023). R1's Incident note, dated 11/21/23, by V9, Licensed Practical Nurse/LPN, documents Resident slid from w/c (wheelchair) while exiting transport van. Small abrasion to forehead. Bleeding stopped and no c/o (complaint of) pain elsewhere. Neuros (neurological signs) WNL (within normal limits). On blood thinner. Witnessed by (V4, CNA/Certified Nursing Assistant). Ambulance call for transport to ER (Emergency Room) further evaluation. R1's Incident note, dated 11/21/23, by V8, LPN, documents Resident returned from (named ER/Emergency Room) due to fall. CT…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-05-13 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility to ensure licensed staff dispensed physician-ordered medications for one of three residents (R1) reviewed for medication administration in a sample of three. Findings include: The facility's Medication Administration General Guidelines, dated 02/26, documents that medications are administered as prescribed in accordance with the manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. This form also documents that medications are prepared only by licensed nursing, medical, pharmacy, or other personnel authorized by state regulations to prepare medications. V4's, Certified Nursing Assistant, Termination Detail, dated 4/16/26, documents involuntary gross misconduct and breach of policy/procedures. V5's, Registered Nurse, Termination Detail, dated 4/16/26, documents involuntary gross misconduct for termination.R1's current Physician Order Sheet documents…

  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 · Fcited before2026-01-30 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to ensure refrigerator and freezer temperatures were monitored and expired food products were discarded and not available for resident use. This failure has the potential to affect all residents who reside in the facility with a current census of 68 residents. Findings include:The Facility Resident Census Roster and Facility Matrix/802, dated 1/27/26, were reviewed. The Census Roster documented 68 Residents resided in the Facility.The Storage Procedures policy documents refrigerated storage temperature will be at 41 degrees Fahrenheit or below and frozen storage temperatures will be 0 degrees Fahrenheit or below. Temperatures will be recorded on the refrigerator and/or freezer log at least twice daily. The Date Marking policy dated 11/20/25 documents items will be marked using the attached food shelf life and dating guidelines. If a food hasn't been opened check the manufacturers date to ensure it hasn't expired. If expired discard and report to manager. The Ice Cream Freezer Temperature Log dated 09/2025,…

  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 · Ecited before2026-01-30 · 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 implement Enhanced Barrier Precautions (EBP) for 4 of 6 residents (R3, R19, R40, R55) reviewed for transmission based precautions in a sample of 33.The facility's Enhanced Barrier Precautions (EBP) Policy, dated 4/15/2025, documents EBP refers to an infection control intervention that employs targeted gown and glove use during high-contact resident care activities to reduce transmission of multidrug resistant organisms (MDROs). EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Signs are to be posted on the door or wall outside the resident room indicating the type of precautions and (Personal Protective Equipment) PPE required as well as ensure PPE is available outside of the resident rooms. 1. R3 is an [AGE] year-old resident admitted to the facility on [DATE] with a diagnosis of Displaced Intertrochanteric Fracture of Left…

  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 · D2026-01-30 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  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 psychotropic medication was necessary based on an appropriate diagnosis, associated behaviors, non-pharmacological intervention were care planned nor was the resident or resident representative informed in advance of the risks and benefits the medication, the treatment alternatives or other options for 1 of 6 residents (R61) who receive psychotropic medications.Findings include:The Psychotropic Medication Management System policy, dated 10/26/22, documents a psychotropic drug includes anti-depressants. Behavior monitoring involves identifying behaviors, the number of behavior episodes and success of interventions. A care plan is developed to reflect specific non-pharmacological approaches to care to meet the individual needs of a resident. Prior to administration of a psychotropic medication, the following must be documented: any new antipsychotic medication order will be discussed and reviewed by the Interdisciplinary Team; must have an…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-01-30 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to have a PASRR Level I (Pre-admission Screening and Resident Review) re-evaluated with a new psychotic diagnosis for one of one resident (R9) reviewed for PASRRs in the sample of 33.R9's admission record documents R9 was admitted to facility on 2/18/23.R9's PASRR Level I screening, dated 2/6/23, documents, PASRR Level I determination: No Level II required - No SMI/ID/RC (Serious Mental Illness/Intellectual Disease/Related Condition). Your Level I screen does not show that you have a serious mental illness or an intellectual/developmental disability (IDD). You do not need more screening unless you have or may have a serious mental illness or an IDD and experience a significant change in treatment needs. R9's Diagnosis Report dated 1/28/26 documents R9 was newly diagnosed with psychotic disorder on 2/28/23. Then on 4/1/23, R9 was newly diagnosed with Vascular Dementia with Psychotic Disturbance, Major Depressive Disorder, and Visual Hallucinations.As of 1/28/26, R9's medical record had no documentation of a new PASRR Level I…

  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 before2026-01-30 · 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 interview and record review, the facility failed to develop a plan of care to address resident specific concerns for three of twenty residents (R5, R9 and R28), reviewed for care plans, in a sample of 33. The facility policy, Person- Centered Care Plan, dated (revised) 11/28/2017 directs staff, Person- centered care means to support the resident in making their own choices and having over their daily lives. The Person- centered care plan is in accordance with professional standards of practice and includes the resident's choice. The plan of care addresses the following: Identification of resident areas of needs, problems, strengths, goals, life history and preferences. 1.R5's Physician Order Sheet, dated January 2026 includes the following medications and diagnosis: 1/22/26 Cipro Oral Tablet 500 MG (milligrams) (antibiotic). Give 1 tablet by mouth two times a day for UTI (Urinary Tract Infection) for 7 Days. A review of R5's current Care Plan, dated 2/14/2025 includes no documentation of R5's current urinary tract infection. On 01/29/2026 at 11:00 A.M., V4/Care Plan…

  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 · D2026-01-30 · 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, record review, and interview, the facility failed to administer medications as ordered by the physician to two (R26 and R60) of nine residents reviewed for medication pass. This failure resulted in two errors out of twenty-eight opportunities for a 6.9 percent medication error rate.Findings include:The facility's Medication Administration policy, undated, documents in section 7.1, page 3, that medications are administered in accordance with written orders of the prescriber.The facility's Medication Ordering and Receiving From Pharmacy Provider policy, dated 1/25, documents that all medications shall be reordered in advance by writing the medication name and prescription number or applying the peel-off bar coded labeled from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to the pharmacyR26's Physician Order Sheet documents for R26 to take Cetirizine HCL Oral tablet 10MG (milligrams) one time a day for allergies.On 1/28/26 at 8:10am, V7, Registered Nurse, prepared all R26's scheduled 9:00am medications except for the…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-11-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to implement safety interventions for a resident at moderate risk for falls while on the toilet for one (R2) of three residents reviewed for falls in a sample of three. The facility's Mechanical Lift policy, reviewed 5/23/25, documents for the Power Stand-Up Lift Procedure: Assemble all supplies within reach, including lift and lift harness. b. Position the top of the harness around the upper body of the resident (approximately 4-5 inches below the underarm). c. Securely fasten the harness safety strap around the resident's chest. This form documents that when lifting a resident from a wheelchair or other chair, secure the harness loops onto the lift. b. Secure the shin straps around the resident's legs. The facility's Falls Prevention and Post-Falls Management policy, reviewed 9/6/25, documents that the staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait balance, excessive motor activity, activities of daily…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-11-15 · tag F0745 — failed to provide medically-related social services — isolated
  Provide medically-related social services to help each resident achieve the highest possible quality of life.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to implement psychosocial service interventions for one of three residents (R1) reviewed for social services in sample of three. Findings include:The facility's Behavioral Health policy, reviewed 12/18/24, documents that the organization will provide residents with behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. This form documents that behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care, and residents who exhibit signs of emotional/psychosocial distress receive services and supportthat address their individual needs and goals for care. On 11/15/25 at 8:45am, R1 stated that he and his wife lived in an apartment in the assisted living portion of the facility. R1 stated that he and his wife had separated and are getting divorced after 40-plus years of marriage. R1 stated that he was moved to the long-term…

  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 before2025-06-27 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow the recommended guidelines to properly treat and disinfect a resident room with suspected bed bugs to prevent the spread of bed bugs for 2 of 3 residents (R1, R2) reviewed for infection control in the sample of 3. The findings include: On 6/27/25 at 9:33 AM, R2 was in him room, sitting in his wheelchair. R2 said the staff reported bed bugs were found in this room on 6/23/25. R2 said they bagged his clothing this time on 6/24/25 (Tuesday) and he moved to another room and came back to his room on 6/26/25. On 6/27/25 at 9:47 AM, R1 was in his wheelchair out of his room on the computer in the lounge area. R1's hair was past his shoulder, long, scraggly, greasy and matted in the back. R1 had a long facial beard approximately 3 inches past his chin. R1 said on 6/23/25, the staff found a bed bug on his blanket near his leg. R1 said he stayed in his room until 6/26/25, when his room was sprayed by a pest exterminator. R1 said when they were…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction

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

Fines & penalties

$87,819 in federal fines across 3 penalties. 2 Medicare payment denials on record.

• $38,711 — penalty dated 2024-12-20
• $21,450 — penalty dated 2024-06-20
• $27,658 — penalty dated 2024-01-11
• Medicare payment denial — starting 2026-05-25 for 14 days
• Medicare payment denial — starting 2024-02-06 for 10 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 21 rows in the source record cover these 12 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.

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

Follow the money — this home’s finances

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

This home reported $494K 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