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Allure Of Peru

1301 21st Street, Peru, IL 61354 · For profit - Individual · 127 certified beds · (815) 223-4901 Medicare & Medicaid certified

Call the home — (815) 223-4901 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0602) — cited Mar 2026Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$10,059 in federal fines
Insights

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

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)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0602), cited Mar 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,059 in federal fines (most recent 2023-12-17)
  • its facility-reported quality-measure rating is low (1/5)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1650 Midtown Rd · (815) 538-1351 · Call to confirm hours
Pharmacy
Walgreens0.2 mi
1033 Shooting Park Rd · (815) 223-7853 · Call to confirm hours
Grocery
Aldi0.2 mi
951 Shooting Park Rd · (855) 955-2534 · Call to confirm hours
Park
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 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 3 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 rating3★
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 increased16.9%13.4%15.4%typical
Long-stay residents who lose too much weight5.4%6.3%5.4%typical
Long-stay residents with a catheter left in their bladder3.6%0.9%0.9%worse
Long-stay residents with a urinary tract infection0.8%1.5%2.0%better
Long-stay residents with depressive symptoms48.9%54.2%6.5%typical for the 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 injury4.6%3.1%3.3%worse
Long-stay residents whose ability to walk worsened15.6%14.3%16.1%typical
Long-stay residents on antianxiety or hypnotic medication27.3%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine96.1%91.8%95.3%typical
Long-stay residents with pressure ulcers6.3%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control26.5%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table16.0%21.7%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.9%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine74.5%63.1%79.4%typical
Short-stay residents rehospitalized after admission23.7%26.1%22.6%typical
Short-stay residents with an outpatient ER visit27.5%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.172.021.67worse
Long-stay outpatient ER visits per 1,000 resident days4.142.221.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

48.9% 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 157 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.9%U.S. median 51.5%
Got home and stayed home
11.2%U.S. median 10.7%
Went back to hospital
4.3%U.S. median 56.6%
Met the expected recovery
0.26U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 4.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 94 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 0.26 therapist hours per resident per day in 2026Q1 — more than 37% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% 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 SNF48.9%CMS range 43.0–57.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.2%CMS range 8.2–15.810.7%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 discharge4.3%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 discharge4.3%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 discharge11.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened6.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 4.0–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.171.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.82
RN hours/ resident / day
0.47
LPN hours/ resident / day
2.67
Aide hours/ resident / day
3.96
Total nurse hours/ resident / day
0.63
RN hoursweekends
40.4%
Total nursing turnover
35.0%
RN turnover

How full it usually is: this home is certified for 127 beds and averages 81.0 residents a day — about 64% occupied, or roughly 46 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.96 hrs/resident/day is at or above 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 2.67 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 3.59 hrs/resident/day on weekends vs 4.10 on weekdays — 12% thinner on weekends. RN hours go from 0.90 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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

8
deficiencies at the latest standard inspection (2025-04-25)
8
at the previous standard inspection (2024-05-16)

Deficiencies are unchanged from the previous inspection. 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.

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2023-12-17 · 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 record review and interview, the facility failed to prevent a safe and secure transfer for one of three (R1) residents reviewed for safe transfers in a sample of three. This failure resulted in R1 falling on 11/15/2023 and receiving a Displaced oblique distal diaphyseal fracture of the left femur. Findings Include: R1's V7/ Physician Assistant History and Physical, dated 11/15/2023, documents the following,(R1's) left leg shortened and internally rotated. Motor limited due to pain. R1's Trauma Level 2 History and Physical, dated 11/15/2023, from V8/ Orthopedic Surgeon documents, [AGE] year-old female Caucasian patient who was brought into the trauma bay, who fell from her wheelchair while being transferred in vehicle. (R1) was found to have a distal left femur fracture. Patient presents with left leg internally rotated, very tender. R1's X-Ray of the left femur, dated 11/15/2023, documents, Displaced oblique distal diaphyseal fracture of the left femur. The fracture is probably acute. Distal fracture…

    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 · G2023-04-21 · 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 observation, interview, and record review, the facility failed to recognize the immediate need for transferring a Covid-19 positive resident to the hospital for necessary medical treatment for one (R26) of four residents reviewed for hospitalization in the sample of 29. This failure resulted in delay of treatment resulting in R26 expiring in the emergency room. Findings include: The facility's Guidelines for Physician Notification of Change in Resident Condition policy, revised 4/2019, documents: Purpose: to define resident care situations that require physician notification. Standard: Staff observe, document and communicate to the physician changes in resident condition promptly .If the nurse is unable to contact the physician, the nurse may, by his/her informed judgment and professional discretion, transfer the resident to the hospital of record for evaluation and treatment. On 4-19-23, at 3:10pm, R26 sat in R26's isolation room in a wheel chair with his head and upper body leaning over the bed with…

    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 · D2026-04-10 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to set up a resident's dialysis treatment and transportation to dialysis upon discharge for 1 of 3 residents (R1) reviewed for discharge planning in the sample of 3.The findings include:R1's face sheet shows R1 was admitted to the facility last 3/11/26 and was discharged last 3/23/26.R1's Physician order sheet dated 3/26 show, R1 has diagnoses that include end stage renal disease and dependence on dialysis. The same POS shows R1 has an order for: R1 to receive hemodialysis three times weekly Monday, Wednesday and Friday. On 4/10/26 at 8:45 AM, V3 (Dialysis Nurse Manager) said the dialysis unit was concerned regarding R1. R1 had not been showing up to receive his dialysis treatment. R1's last dialysis treatment was 3/20/26. R1 missed his dialysis on 3/23/26 and again on 3/25/26. V3 said on 3/25/26 the dialysis unit called the facility to find out what was going on with R1. V3 said messages were left but no one at the facility returned the call. V3 said she…

    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 before2026-03-18 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure that controlled substances were reconciled and stored appropriately. This has the potential to affect all 82 residents residing in the facility. The facility's Medication Storage policy, undated, documents to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperatures, light, ventilation, moisture control, segregation, and security. This form also documents that schedule II drugs and back-up stock of schedule III, IV, and V medications are stored under double-lock and key. This form documents that schedule II controlled medications are to be stored within a separately locked, permanently affixed compartment when other medications are stored in the same area, such as in a refrigerator. The facility's Controlled Substance Administration and Accountability policy, undated, documents that all controlled substances obtained from a non-automated medication cart or…

    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 · D2026-03-18 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    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 interventions were in place to prevent misappropriation of a medication for one of three residents (R1) reviewed for misappropriation of property in a sample of three. Findings include:The facility's Abuse and Retaliation Policy Prevention Program, dated 01-2026, documents that the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. The Proof of Delivery form, dated 2/7/26, documents that a bottle of Lorazepam (benzodiazepine) 2mg/ml (milligrams per milliliter), 30ml, was delivered and signed in by V4, Registered Nurse. The facility's Final Summary of Investigation, undated, documents that R1 had an order for Lorazepam Oral Concentrate 0.25ml by mouth every two hours as needed for anxiety for 14 days. This form documents that on 2/13/26, V2, Director of Nursing, was notified by V3, Assistant Director of Nursing, that she had been made aware of an incorrect narcotic count for R1. V2…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident at risk for falls who was placed in the bathroom had access to a call light for safety. This applies to 1 of 5 residents (R1) in the sample of 5 reviewed for safety. The findings include: R1's face sheet shows she has diagnoses including pneumonia, heart failure, COPD, atrial fibrillation, abnormalities of gait and mobility, anxiety, unsteadiness on feet, dependence on supplemental oxygen, and osteoarthritis. On 9/26/25 at 9:32 AM, R1 was observed sitting in her recliner chair in her room, she was wearing oxygen, and her phone was attached to a lanyard around her neck. R1 said she was placed in the bathroom and was told to ring when she was done. R1 said she was not given the bathroom call string and waited in the bathroom for a long time. R1 said the bathroom call string to pull was broken. The string was detached from the wall unit, she never pulled the cord because the cord was on the ground. R1 said she waited on the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain the privacy of residents' health information for two (R12 and R174) of 18 residents reviewed for confidentiality/privacy in a sample of 31. Findings include: The undated Residents' Rights for People in Long-Term Care Facilities documents Your rights to privacy and confidentiality - You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. On 4/23/25, between 8:29am and 8:45am, V4 Registered Nurse/RN administered medications to R12 and R174 in the dining room. V4's medication cart sat in a high traffic hallway between two dining rooms in the front portion of the facility. On 4/23/25, at 8:29am, V4 RN stood at the medication cart, opened R12's electronic medical record on the lap top computer sitting on top of the medication cart, and prepared R12's medications. V4 then left the medication cart with the computer screen unlocked and open showing a view of R12's clinical record. While V4 was away from the medication cart…

    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 · D2025-04-25 · 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 ensure fingernail care was added to a resident's Care plan for one (R40) of 18 residents reviewed for Care plans in a sample of 31. Findings include: The facility's undated Comprehensive Care Plans policy documents Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the Resident's personal and cultural preferences in developing goals of care. The facility's undated Nail Care policy documents Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good…

    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 · D2025-04-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to perform nail care for two residents (R19) and (R40) of 18 reviewed for assistance with daily living in a total sample of 31. Findings Include: The facility's undated Nail Care policy documents Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during ADL (Activities of Daily Living) care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5. The Resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. c. The person(s) responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist,…

    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 · D2025-04-25 · 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 ensure glove change during pressure ulcer treatment for one (R27) of seven residents reviewed for pressure ulcers in a sample of 31. Findings include: The facility's undated Clean Dressing Change policy documents Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: 7. Wash hands and put on clean gloves. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound. Pat dry with gauze. R27'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to document behaviors to justify the use of psychotropic medications for two residents (R6 and R46) and failed to attempt nonpharmacologic interventions for one resident (R46) of five residents reviewed for unnecessary medications in a total sample of thirty one. Findings Include: The Facility's undated Use of Psychotropic Medications policy documents It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Psychotropic medications are to be used only when a practitioner determines that 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 before2025-04-25 · 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 medications were administered according to physician orders and pharmacy medication instructions for two (R12 and R48) of six residents reviewed during Medication Administration in a sample of 31. There were two errors out of 26 medication opportunities observed resulting in a 7.69% medication error rate. Findings include: The facility's Medication Administration policy, dated 2025, documents Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed: a. Right resident. b. Right drug. c. Right dosage. d. Right route. e. Right time. f. Right documentation. 17. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid.…

    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
Show the remaining 18 citations
  • Potential for harm · Dcited before2025-04-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to keep residents' medications securely stored for two (R12 and R174) of seven residents reviewed for medication storage during medication administration in a sample of 31. Findings include: The facility's undated Medication Storage policy documents Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. On 4/23/25, at 8:25am, V4 Registered Nurse's/RN'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 accuracy of resident medical records for two (R40 and R48) of 18 residents reviewed for medical records in a sample of 31. Findings include: The facility's Documentation in Medical Record policy, dated 2024, documents Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 4. Principles of documentation include but are not limited to: a. Documentation shall be factual, objective, and resident centered. I. False information shall not be documented. ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided. b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. The facility's Certified Nursing Assistant job…

    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 · D2025-01-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to report potential allegations of theft to the local law enforcement for two (R1 and R2) of four residents reviewed for misappropriation of property in a sample of four. Findings include: The facility's Abuse, neglect and Exploitation policy, dated 7/1/24, documents Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. B. Possible indicators of abuse include but are 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-05-16 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to utilize PPE (Personal Protective Equipment), failed to perform hand hygiene during medication pass, failed to initiate enhanced barrier precautions and failed to sanitize equipment after usage in an enhanced barrier precaution room for six residents (R2, R12, R32, R58, R14 and R281) of 24 reviewed for infection control. This has the potential to affect 79 residents residing in the facility. Findings include: The facility's Cleaning and Disinfection of Resident-Care Equipment, dated 7/1/23, documents that resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. This form also documents that multiple-resident use equipment shall be cleaned and disinfected after each use. The facility red Enhanced Barrier Precautions sign from the United States Department of Health 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
  • Potential for harm · D2024-05-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each 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 provide a resident with a mirror to allow for self grooming for one (R66) of one resident reviewed for Accommodations of Need in a sample of 35. Findings include: The facility's Activities of Daily Living (ADLs) policy, dated 7/1/23, documents The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. On 5/13/24, at 9:40am, R66 was lying in bed with visible facial hair. R66 stated I can't see myself in the mirror from my wheelchair, only from the forehead up. It is part of the reason I haven't shaved. I know it (my beard) looks bad. R66's Care plan includes a focus of: (R66) is at risk for an ADL Self Care Performance Deficit related to Activity Intolerance, Impaired balance, bilateral AKA (Above the Knee Amputation). The goal is:…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 a person centered baseline care plan for two residents (R281 and R283) of five reviewed for baseline care plans in a sample of 35. Findings include: The facility's Baseline Care Plan, undated, documents that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. R281's admission orders, dated 5/4/24, documents the following diagnosis: fracture of the neck of the left femur, acute urinary tract infection, acute metabolic encephalopathy, dementia, hard of hearing, lacunar stroke and mild aortic insufficiency. R281's base line care plan does not address R281's personalized needs. R283's Progress Notes, dated 5/10/24 documents that R283's referral (to another facility) was denied due to R283's history of suicidal ideation's. On 05/14/24 at 2:00pm, R283 stated that she had some concerns a while back with suicidal ideation's and mental disorders. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an order was placed and a resident was wearing a recommended assistive device for one (R62) of one resident reviewed for Limited Range of Motion in a sample of 35. Findings include: The facility's Prevention of Decline in Range of Motion policy, dated 7/1/23, documents 3. Appropriate Care Planning. a. Based on the comprehensive assessment the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: i. Appropriate services (specialized rehabilitation, restorative, maintenance). ii. Appropriate equipment (braces or splints). R62's current Face Sheet documents R62 admitted on [DATE] with an admitting diagnosis of Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting left non-dominant side. On 5/13/24, at 9:28am, R62 was sitting in…

    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 before2024-05-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to ensure psychotropic medication ordered PRN (as needed) was limited to 14 days for one (R39) of three residents reviewed for Unnecessary Medications in a sample of 35. Findings include: The facility's undated policy, Use of Psychotropic Medication documents, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medications(s). This policy also states 9. PRN (as needed) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-16 · 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 by the physician for two residents (R58 and R72) on the sample of 7 residents reviewed for medication pass. This failure resulted in two medication errors out of twenty- five opportunities for error, for an 8% medication error rate. FINDINGS INCLUDE: The facility policy, Medication Administration, dated (7/1/23) directs staff, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation. 1. R58's current Physician Order Sheet, dated May 2024 includes the following medications: Carafate (anti-ulcer) 1 GM (Gram) by mouth three times daily. On 5/13/24 at 11:16 A.M., V6 Registered Nurse (RN) prepared to administer medications for R58. V6…

    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 · D2024-05-16 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 by the physician for one resident (R72) of seven residents reviewed for medication administration, in a sample of 35. The undated facility policy, Intravenous Therapy directs staff, The facility will adhere to accepted standards of practice regarding infusion practices. Review and verify practitioner's order for infusion solution or medication, dose, frequency and route of administration. R72's current Physician Order Sheet, dated May 2024 includes the following diagnoses: Osteomyelitis Of Vertebra, Thoracic Region; Methicillin Resistant Staphylococcus Aureus Infection; Type 2 Diabetes Mellitus. This same sheet includes the following medications: Vancomycin HCl ((Hydrochloride)Intravenous Solution 2500 mg intravenously in the morning. On 5/14/24 at 8:20 A.M., V6 (Registered Nurse/RN) mixed 20 ML (Milliliters) of Sterile Water into (3) vials of Vancomycin 1 GM (Gram) powder. V6 then withdrew all 20 ML of 2 bottles and 10 ML of the third bottle and injected the mixed solution…

    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 · D2024-05-16 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 pureed bread was provided for residents' lunch for three (R19, R38, and R60) of three residents reviewed for Pureed Diets in a sample of 35. Findings include: The facility's undated Explanation of Diets Pureed policy documents Pureed regular bread and specialty breads such as corn bread, muffins, garlic bread, etc., continue to be pureed as a separate menu item. Pureed bread items may be served hot or cold but need to be held at the appropriate temperature throughout the meal service. The facility's undated Week at A Glance with Portion Pureed menu for Week 4 documents the following meal to be served on 5/14/24: Pureed Baked Ham, Pureed Au Gratin (which was substituted with Cheesy Mashed Potatoes), Pureed peas, Pureed bread/margarine and pureed strudel stick. On 5/14/24, between 10:36am -10:48am, V5 Cook/Assistant Manager pureed ham then Brussel sprouts for today's menu. On 5/14/24, at 11:42am , V5 began serving up plates from the steam table. During this time there was no pureed bread on the steam…

    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 · F2023-04-21 · 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 staff failed to wear hair nets, while in the kitchen, during meal service. This failure has the potential to affect all 80 residents currently residing in the facility. FINDINGS INCLUDE: The facility policy, dated 02/2022, Personal Hygiene: Illness, Shoes, Hair Restraints directs staff, Employee shall use effective hair restraints such as hats, hair coverings or nets, beard restraints and clothing that cover body hair that are designed and worn to effectively keep their hair from contacting exposed food and clean equipment. Anyone entering a kitchen or serving area will have their hair restrained and/or a beard guard. This will be worn throughout the time in the kitchen and when handling food. On 4/18/23 at 11:48 A.M., V6/Dietary Services Manager (DSM), V8/Assistant Dietary Services Manager and V9/Dietary Aide were serving the noon meal. At that time, V7/Unit Aide (UA) opened the kitchen door, stated, 'I need ice water' and with her hair unrestrained, entered the facility kitchen from the north door, grabbed an empty…

    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 · D2023-04-21 · 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 respond to resident call devices promptly for two (R35 and R59) of 18 residents reviewed for call devices in a sample of 29. Findings include: The facility's Call Light policy, dated 8/1/05, documents Objective: 1. To respond to resident's requests and needs. Procedure: 1. Answer call light promptly. The facility's Resident Council meeting minutes contain the following information: Meeting held on 1-24-23 Nursing: Call lights not being answered in timely manner. This is every hall and different times of the day. Meeting held on 2-28-23 Nursing: The call lights are not being answered in a timely fashion. This is on different halls. Meeting held on 3-28-23 Nursing: Call lights not being answered on pm's and nocs (nights). On 4-20-23, at 12:17pm V2 Director of Nursing/DON stated that the resident call device response times go into overtime after 15 min so they should be answered before that. 1. On 4-18-23, at 9:45am, R59 sat in a recliner in R59's room. R59 stated that (R59) waited for two hours at 2am this…

    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 · D2023-04-21 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS-10055 (Centers for Medicare and Medicaid Services) to two (R32, R36) of three residents reviewed for Beneficiary Protection Notification in the sample of 29. Findings include: 1. R32's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form provided by V1 Administrator documents R32's Medicare Part A Skilled Services Episode Start Date as 10/13/22 and last covered day of Part A Service as 1/17/23. This form documents that R32 remained in the facility; and that the SNF ABN Form CMS-10055 was not provided to R32 or R32's Representative. 2. R36's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form provided by V1 Administrator documents R36's Medicare Part A Skilled Services Episode Start Date as 1/28/23 and last covered day of Part A Service as 3/17/23. This form documents that R36 remained in the facility; that R36 had benefit days remaining; and that the SNF ABN Form CMS-10055 was not provided…

    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 · D2023-04-21 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to notify the Long Term Care Ombudsman of residents' transfer/discharge to the hospital for three (R37, R46, R69) of four residents reviewed for emergency hospital transfer in the sample of 29. Findings: The facility's Provision of Notice Before a Facility Initiated Transfer or Discharge Policy, Dated 11/2022, documents: The facility will notify the resident and representative before a facility initiated transfer or discharge. This notification will include the reason for the move and will be written in a language that the resident and representative understand. A copy of this notice shall also be sent to the Long-Term Care Ombudsman. For the emergency facility-initiated transfers, a copy of the notice would be sent to the Ombudsman as soon as practicable or at least monthly. 1. R37's Progress Notes document R37 had a fall on 3/7/23, was sent to the hospital on 3/7/23, and returned to the facility on 3/7/23. 2. R46's Progress Notes document R46 had a fall on 2/6/23, was sent to the hospital on 2/7/23, and returned to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-21 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to provide a copy of the bed hold policy for two (R37, R69) of four residents reviewed for emergent transfer in the sample of 29. Findings include: The facility's Bed Hold Policy, Undated, documents: When a resident is transferred to a hospital, or when the resident takes a therapeutic leave of absence, they have the right to request that their bed be held until their return. The bed hold notification will be issued at the time of transfer and in cases of emergency transfer, notice will be given within 24 hours of the leave. 1. R37's Progress Notes document R37 had a fall on 3/7/23, was sent to the hospital on 3/7/23, and returned to the facility on 3/7/23. 2. R69's Progress Notes document R69 had a fall on 2/16/23, was sent to the hospital on 2/16/23, and returned to the facility on 2/16/23. R37 and R69's medical records did not contain documentation of bed hold policy given with hospital transfers to residents and/or representatives. On 4/19/23 at 12:10pm, V1 Administrator stated that bed hold policies were not provided 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 resident oxygen humidifiers were changed as ordered and full while in use for one (R59) of two residents reviewed for oxygen in a sample of 29. Findings include: The facility's policy Oxygen Concentrator Use, revised 3/2008, documents Procedure: 10. Water or pre-filled humidifier bottles are to be changed weekly, and when empty, dated and initialed. NOTE: Humidifier bottles are not necessary unless the resident is receiving oxygen at 3L/min (liters per minute) or greater, is symptomatic for dry mucous membranes or requests humidity for comfort reasons. On 04-18-23, at 9:45am, R59 sat in R59's room with oxygen infusing at 4 lpm (liters per minute) per nasal cannula. R59's oxygen concentrator humidifier bottle, dated 4/11, is empty. R59 stated it feels like it. On 04-19-23, at 8:32am, R59 sat in R59's room with oxygen infusing at 4 lpm per nasal cannula. R59's oxygen concentrator humidifier bottle, dated 4/11, remains empty. At this time, V11 Licensed Practical Nurse/LPN verified R59's humidifier bottle…

    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 · D2023-04-21 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to obtain a physician's order for the implementation of dialysis and failed to ensure a resident's dialysis needs were addressed fully in a care plan for one of one resident (R12) reviewed for dialysis in the sample of 29. Findings Include: R12's current Physician Order Sheet, dated April 2022 documents that R12 was admitted to the facility on [DATE] with the following diagnoses: End Stage Renal Disease, Chronic Kidney Disease, Acute Kidney Failure and Dependence on Renal Dialysis. Also included are the following physician orders: Monitor port to RT upper chest for any signs and symptoms of infection; Weekly weights. No physician orders for the implementation of Hemodialysis is noted. R12's Care Plan, dated 9/11/2019 includes the following focus area: (R12) is on dialysis (hemo) related to renal failure. Also included are the following Interventions: Encourage (R12) to go to scheduled dialysis appointments; Maintain fluid restriction; Monitor…

    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

“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

$10,059 in federal fines across 1 penalty.

  • $10,059 — penalty dated 2023-12-17

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

Part of a chain

This home belongs to ALLURE HEALTHCARE SERVICES — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.6+0.4 vs chain
Health inspection 4 of 53.0+1.0 vs chain
Staffing 3 of 51.7+1.3 vs chain
Quality measures 1 of 52.6-1.6 vs chain
The other 14 homes this chain runs (chain average 2.6★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
MN1 MANAGEMENT CORPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL30%since 07/01/2023
GOLDBERG, JEREMYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL30%since 07/01/2023
OSEROFF, MEYERIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL30%since 07/01/2023
WENGROW, DAVIDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 07/01/2023
NUDELL, MICHAELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL30%since 07/01/2023
WALTERS, KATRINAIndividualW-2 MANAGING EMPLOYEEsince 07/01/2023
MEYER, SAMANTHAIndividualCORPORATE OFFICERsince 07/01/2023

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$4.5M
Net patient revenuemost recent cost report
-4.6%
Operating marginrevenue minus expenses
$326K
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 56%Medicare 14%Other / private 31%

This home reported $326K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$344per resident / day
operating cost
$10,466per month
≈ monthly operating cost
$329per 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 145044. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, 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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