Accolade Healthcare Of Pontiac
300 West Lowell, Pontiac, IL 61764 · For profit - Corporation · 97 certified beds · (815) 842-1181 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited May 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 3 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 $19,250 in federal fines (most recent 2026-06-17)
- its payroll-based staffing rating is low (2/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.3% | 13.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 10.9% | 6.3% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.4% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 59.7% | 54.2% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.9% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 17.2% | 14.3% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 23.2% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 87.1% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.8% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.4% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.4% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.9% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 31.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 25.4% | 13.9% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.38 | 2.02 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.21 | 2.22 | 1.80 | worse |
‡ 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.
49.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 61.9% 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 42 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 0.07 therapist hours per resident per day in 2026Q1 — more than 3% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 49.3%CMS range 39.4–59.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.6–17.1 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 61.9% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 50.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.5% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 96.5% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 4.2–11.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 97 beds and averages 79.8 residents a day — about 82% occupied, or roughly 17 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 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 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 3.13 hrs/resident/day on weekends vs 3.70 on weekdays — 15% thinner on weekends. RN hours go from 0.78 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2026-06-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, interview and record review the facility failed to use foot pedals when transporting a resident in a wheelchair and failed to follow a care plan intervention to utilize a mechanical lift to transfer a resident for two (R2 and R7) of three residents reviewed for accidents in the sample of eight residents. These failures resulted in R2 falling from the wheelchair and suffering a head laceration requiring sutures and R7 suffering a fractured rib when staff transferred R7 without using the mechanical lift. Findings Include:1. According to the current Electronic Health Record (EHR), R2 has diagnoses including unspecified hydronephrosis, weakness, repeated falls, muscle wasting and atrophy of the bilateral thighs, lack of coordination, abnormal posture, cognitive communication deficit, chronic fatigue, osteoarthritis, obesity, anemia, lymphedema, and hypertension.The Care Plan Dated Revised on 5/14/2026 documents R2 as requiring assistance during transfers and being at high risk for falls related to weakness and non-compliance with transfer recommendations 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.
- Actual harm · Gcited before2026-03-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 ensure safe transfer techniques were implemented for one (R1) of three residents reviewed for accidents. The resident sustained a fracture of the left knee when a mechanical lift transfer requiring two staff members was performed by only one staff member.Findings Include The Facilities Hydraulic Lift (Hoyer) Policy revised on 1/26 documents all nursing staff will be trained on the proper use of the hydraulic (hoyer) lifts that are used within the facility, to ensure safe transfer for residents. This Policy also documents that the staff is to obtain assistance from a second staff member.On 11/29/26 at 3:04AM, the Nursing Progress notes documents: R1was sent to the hospital after complaining of pain in the area above her left knee. R1 received Norco (pain medication) just before leaving for the hospital. The hospital gave R1 Tylenol, Fentanyl and Ketorolac for pain management. R1 returned from hospital at 6:00AM. The Hospital diagnosis after the left knee…
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.
- Actual harm · G2024-08-23 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 implement an ordered nutritional supplement and failed to notify a resident representative of the significant weight loss for one of two residents (R379) reviewed for nutrition in the sample list of 26. These failures resulted in R1's severe weight loss of 10.8% in 12 days. Finding include: On 8/20/2024 at 11:55 AM, R379 was sitting in a wheelchair in the dining room eating lunch with V17 (family) present. No nutritional supplements were present on the tray. At this time, V17 states R379 has lost a lot of weight since his surgery, which was prior to being admitted to the facility. V17 is not aware of any ordered nutritional supplements and has not been notified by the facility of any weight loss since R379 being admitted . V17 stated V17 is at the facility for most of R379's meals and acknowledges that R379 has a decreased appetite and intake. R379's ongoing Census documents R379 was admitted to the facility of 8/07/2024. R379's ongoing Weight Log documents a weight of 149.8 pounds on 8/07/2024 and 133.6…
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.
- Potential for harm · Ecited before2026-06-17 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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 ensure residents' rights to dignity, respect, and timely assistance were maintained by failing to respond to call lights in a timely manner for three (R3, R4 and R8) of four residents reviewed for call light response time in the sample list of eight. Findings Include: The facility's grievance logs for April, May, and June 2026 document concerns related to delayed call light response times, including complaints that call lights were not monitored, and response times exceeded acceptable limits.The facility Resident Privacy and Dignity Policy revised 1/26, documents the facility is responsible for ensuring all residents are provided dignity and respect at all times. The policy further requires staff to respond appropriately to resident needs as part of maintaining a home-like environment that promotes dignity and respect.On 6/15/2026 at 10:45 a.m., R3 reported waiting over 45 minutes for R3's call light to be answered.On 6/15/2026 at 10:59 a.m., a call light was flashing at the nursing station with no Certified…
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.
- Potential for harm · D2026-06-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 interview and record review, the facility repeatedly failed to follow physician's orders to utilize a Bilevel Positive Airway Pressure (BiPAP) machine and failed to notify the physician when the BiPAP was not administered for one (R1) out of three residents reviewed for quality of care on a sample list of eight. R1's Administration Record dated April of 2026 documents an order, with a start date of 4/4/26, for R1 to wear a BIPAP every night.A Resident/Family Concern Grievance Form dated 4/6/26 at 9:00AM, documents R1 was concerned that his BiPAP was not at the facility when he admitted to the facility.An email exchange from V13 (Admissions/Marketing Coordinator) with the equipment company, dated 4/10/26, documents V13 notified the equipment company of an issue with R1's BiPAP tubing. The equipment company responded with information and V13 confirmed she would follow-up if the staff could not figure it out.R1's Orders-Administration Note, dated 4/10/26 at 7:07PM, documents that R1's BiPAP was not applied because it needs different equipment to function correctly.R1'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.
- Potential for harm · D2026-06-17 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 record review and interview the facility failed to ensure resident records were accurate for one of two residents (R7) reviewed for documentation accuracy on a sample list of eight.Findings Include:1. R7's Nursing Note dated 6/11/26 at 2:31 PM documents, (V21 Medical Director) also assessed resident, resident had no pain or discomfort in the rib area. No signs of fracture of the area. (V21) stated it looked like a noddle (sic) or legion. (Xray Company) called to re-review Xray and call back with findings.On 6/16/26 at 11:30AM, V5 (Assistant Director of Nursing) stated V21 (Medical Director) physically assessed R7 for a fracture.On 6/16/2026 at 11:16AM, V21, (Medical Director), stated he reviewed radiographs for R7 at the request of facility administration and referred to the radiologist. V21 stated he did not physically assess or see R7. V21 was stopped by V1 (Administrator) on his way out the door to have him review the radiographs.R7's Nurse's Note dated 6/12/26 at 9:56 AM authored by V1 (Administrator) documents, (V20 Physician) also assessed imaging and also did not see…
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.
- Potential for harm · D2026-05-05 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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
Based on observation, interview, and record review, the facility failed to protect a resident from physical abuse by another resident. This failure affects two residents (R1 and R2) out of twelve residents reviewed for abuse on the sample list of 26.Findings include:R1's Medical Diagnoses List dated 5/1/26 documents R1 experiences Delusional Disorder and Major Depression.R2's Medical Diagnoses List dated 5/1/26 documents R2 experiences Delusional Disorder, Dementia, and Paranoid Schizophrenia.The facility's Initial Report to Illinois Department of Public Health dated 3/28/26 documents an occurrence between R1 and R2 with R1 scratching R2 on the arm.R1's Nursing Progress Notes dated 3/19/26, 3/20/26, 3/21/26, 3/23/26, and 3/24/26 documented R1 exhibiting behaviors, albeit these behaviors are not specified. On 3/25/26 R1's Nursing Progress Note documents R1 being upset and yelling at staff.On 3/24/26 R1's Nursing Progress note documents: Note Text: Was a behavior observed? YES. Res upset this morning due to (R1) does not like the Certified Nursing Assistant on (R1's) hallway. One 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.
- Potential for harm · D2026-03-12 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure an incident resulting in a fracture was reported to the State Agency within the required timeframe for one (R1) of three residents reviewed for Accidents. Findings IncludeThe Facilities Accidents and Incidents policy revised on 1/26 documents that reporting accidents and incidents, including injuries of an unknown origin, must be reported to the department supervisor and an Accident/Incident Report form must be completed on the shift that the accident or incident occurred. This document also states that the Director of Nursing (DON)/Designee will report any accident/incident of major injury to the State Agency within 24 hours.On 11/29/26 at 3:04AM, R1's Nursing Progress note documents R1 was sent to the hospital after complaining of pain in the area above R1's left knee. R1 received Norco for pain management just before leaving for the hospital. The Hospital gave R1 Tylenol, Fentanyl and Ketorolac for pain management. R1 returned…
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.
- Potential for harm · Dcited before2026-03-12 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure documentation of the required transfer/discharge process for one (R3) of three residents reviewed for transfer/discharge. The facility discharged R3 without documentation of the required discharge notice and required elements in the medical record.The Facility Discharge/Transfer Policy revised 1/25 documents the facility is to provide guidelines for appropriate discharge and transfer procedures. The facility also documents that the facility will have a written or telephone order from the attending physician for the transfer or discharge of a resident. R3 was admitted to the facility on [DATE] per R3's nursing progress notes.Per R3's Hospital notes dated 2/23/26, R3 was dropped off at the Emergency Department (ED) from the facility with complaints of social concern. Per the facility, it was discovered during R3's background check that R3 had a sexual offense and could not be admitted to the facility. The Facility attempted to find different…
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.
- Potential for harm · Dcited before2025-08-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Based on Interview, Observation and Record Review the facility failed to follow admission orders for c-collar care for one (R1) out three residents reviewed on a sample list of three. Findings Include:On 7/18/2025, R1 had a fall that resulted in a C2 fracture of the neck. R1 was sent to the emergency room for evaluation due to pain in the left shoulder and returned on 7/19/25 with an Aspen C-Collar (Cervical Collar) and orders for care of the C-Collar. On 8/2/25 at 8:05AM, V8 (Certified Nursing Assistant) stated V8 put resident (R1) to bed on 7/18/25, there was no recliner in the room, which V8 stated that R1 usually sleeps in recliner. On 7/18/25, V8 found resident (R1) had rolled out of bed and was complaining of shoulder pain and with the assistance of V9 (Certified Nursing Aide) and V10 (Registered Nurse) resident (R1) was put back to bed via Hoyer lift.On 8/2/25 at 1:18 PM, V10 stated that after resident (R1) returned, the facility received orders to complete skin checks weekly. V10 stated since the bed had been taken out, there was only a recliner in the room and R1's c collar…
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.
- Potential for harm · Dcited before2025-06-23 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 two (R1, R2) of three residents reviewed for infection control in the sample list of three. Findings include: The facility's Enhanced Barrier Precautions policy dated 1/20/24 documents EBP is an intervention designed to reduce the transmission of multidrug-resistant organisms by using gowns and gloves during high contact resident care activities for residents with indwelling medical devices or chronic wounds. The Centers for Disease Control and Prevention Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021 documents Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE (Personal Protective Equipment) required and defining high risk resident care activities. Gowns and gloves should be available outside of each resident room,…
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.
- Potential for harm · Ecited before2025-06-04 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for five of five residents (R9, R26, R50, R63 and R74) reviewed for hospitalizations on the sample list of 35. The facility's Bed Reserve Policy Notification no date, documents this bed reserve policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. 1. R9's Nursing Notes document R9 was transferred to the emergency room on 3/29 and 5/25/25. R9's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R9's representative for R9's hospitalizations on 3/29 and 5/25/25. The facility could not provide documentation that R9's representative was provided a written copy of the Bed Hold Policy when R9 was transferred to the emergency room on 3/29 and 5/25/25. 2. R26's Nursing Notes document R26 was transferred to the emergency room on 5/14 and 5/25/25. R26's medical record…
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.
- Potential for harm · Ecited before2025-06-04 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide 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 interview and record review, the facility failed to provide numerous showers as scheduled for dependent residents. These failures affect two residents (R34 and R63) of six reviewed for activities of daily living in the sample list of 35. Findings include: The facility's Bath/Shower Policy dated 8/2023 documents: Purpose: To provide a procedure for bathing/showering the resident. Policy: A bath/shower for cleanliness and comfort will be scheduled at least weekly for all residents. Responsibility: It's the responsibility of the nursing assistants to provide the bath/shower to each resident per schedule. It is the responsibility of the Charge Nurse to ensure that bath/shower schedule is followed, and residents receive bath/shower per facility schedule. 1. R34's Facility Census documents R34 was admitted to the facility on [DATE] and has the following medical diagnosis; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Aphasia, Lack of Coordination, Convulsions, Major…
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.
Show the remaining 17 citations
- Potential for harm · D2025-06-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan. This failure affects one (R50) of 19 residents reviewed for care plans in the sample list of 35. Findings include: The facility's Care Planning Policy (revised June 2024) documents the following: To utilize the results of the comprehensive assessment to develop, revise and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consonant with the physician's plan of care. The resident care plan must be kept current at all times. On 6/1/25, 6/2/25, 6/3/25, and 6/4/25 during…
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.
- Potential for harm · Dcited before2025-06-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility staff failed to provide complete incontinence care for R18. R18 is one of one resident sampled for incontinence care in a total sample of 35. Findings include: The Electronic Medical Record under the section Medical Diagnoses dated 6/3/25 documents the primary diagnosis for R18 is Unspecified Cord Compression. Progress Notes dated 5/13/25 and 6/3/25 document R18 received antibiotics for urinary tract infections. V18, CNA (Certified Nurse Assistant) performed incontinence care for R18 on 6/3/25 at 2:40 PM. V18, used wash clothes to cleanse, rinse and dry R18's inner and outer labia. V18 then stated she was completed with perineal care for R18. V18 was asked about cleaning the groin area and the buttocks. V18 said Yes I should of cleaned R18's buttock's area. R18 stated on 6/3/25 at 2:35 PM she was feeling strange and she had started a new antibiotic today (6/3/25) for another urinary tract infection. V1, Administrator stated on 6/3/25 at 3:15 PM Yes, they are supposed to clean the entire area front and back when staff…
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.
- Potential for harm · D2025-06-04 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to have an order for the provision of dialysis treatments for two (R13 and R46) of two residents reviewed for dialysis in the sample list of 35. Findings include: The facility's Long-Term Care Facility Renal Dialysis Affiliation Agreement dated 11/8/2019 documents the Dialysis Facility shall accept medically stable residents into its home Renal Dialysis program, within the limits of its programs and facilities, Each such resident accepted into the Dialysis Facility's home hemodialysis program is referred to herein as a Dialysis Resident. The medical management of the Dialysis Residents will be under the direction of each Dialysis Resident's attending physician. The LTC Facility retains primary responsibility for the development and implementation of each Dialysis Resident's overall plan of care. Coordination of care may include coordination of the following: Day(s), date(s), and time(s) of appointments with the Dialysis Facility and dialysis access…
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.
- Potential for harm · Dcited before2025-06-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two (R2 and R275) of seven residents reviewed for EBP on the sample list of 35. Findings include: The facility's Enhanced Barrier Precautions policy dated 10/21/22 documents EBP expands the use of gloves and gowns to be worn during high-contact care activities that provides opportunities for Multidrug Resistant Organisms (MDROs) to be transferred between staff hands or clothing and between residents during these high-contact cares. This policy documents residents with wounds and indwelling medical devices are at high risk of acquisition and colonization of MDROs. This policy documents to wear gown and gloves when assisting residents on EBP with high-contact care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, providing device care or wound care. R2's care plan dated 4/8/24 documents that staff will always maintain EBP during high-contact resident care areas. R2'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.
- Potential for harm · Fcited before2024-08-23 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 maintain the facility kitchen food service areas, and equipment in a clean, sanitary condition to prevent potential cross-contamination and food-borne illness to residents. This failure has the potential to affect all 76 residents residing in the facility. Findings include: On 08/20/24 at 9:50 am, during the initial tour of the facility kitchen, accompanied by V7, Dietary Manager (DM), the commercial table mounted can opener had a build-up of a grease-like substance in the gears. Adhering to the grease-like substance were metal fragments, and rust. The commercial can opener also had the silver laminate missing from the bottom inch of the blade. The commercial can opener blade had exposed bare metal and rust at the tip of the blade. V7, DM confirmed the observation and stated he would have to get the build-up debris and blade tip cleaned properly before using the can opener. During the same initial tour, the facility flat-top grill and stove burners had a range hood that spanned over all cook surfaces. The range…
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.
- Potential for harm · E2024-08-23 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 residents medications, including Schedule II controlled substances, were stored appropriately within visual control of the nurse. This failure affects four of 22 residents (R2, R31, R35, R25) reviewed for medication storage for the sample list of 26. Findings include: On 8/21/2024 at 4:09 PM, the [NAME] Wing Medication Cart was unlocked and not secured to the wall. There were no staff present. There was an opened stock bottle of Melatonin 5 mg (milligrams) sitting on top of medication cart. On 8/21/2024 at 4:10 pm, V16 LPN (Licensed Practical Nurse) exited the [NAME] Wing Medication Room and walked down the hall and into a resident room, leaving the unsecured medication cart in the hallway, unlocked and out of V16's sight. V16 returned to the medication cart at 4:12 PM, gathered supplies and walked away from the cart again at 4:17 PM and entered another resident room, leaving the cart unlocked, unattended and out of V16's sight until 4:20 PM. V16 returned to the cart at 4:21 PM to gather supplies, then…
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.
- Potential for harm · Dcited before2024-08-23 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Failures at this level require more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to respect a resident's right to have a visitor with a service support animal present during meal service for one of 18 residents (R377) reviewed for resident rights in the sample list of 26. B. Based on observation, interview, and record review the facility failed to ensure a resident's right of dignity by failing to cover a resident's exposed abdomen in the dining room where other residents were present. This failure affected one of eighteen residents (R24) reviewed for dignity on the sample list of 26. Findings include: The facility policy Resident Privacy and Dignity dated as revised October 2023, documents the following: PURPOSE: To provide all residents with a home like environment that promotes dignity and respect to the residents of the facility. POLICY: To ensure that all residents are provided with dignity and privacy. RESPONSIBILITY: It is 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.
- Potential for harm · Dcited before2024-08-23 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Based on observation, interview, and record review the facility failed to obtain an order for a therapy recommended arm sling and failed to assist in applying the arm sling for one of one resident (R377) reviewed for Limited Range of Motion in the sample list of 26. Findings include: On 8/20/2024 at 10:36 AM, R377 was sitting in wheelchair with V5 (family) present. V5 stated R377 had a fall while at home and sustained a fractured right shoulder and should have an immobilizer on. At this time R377 states R377 was sitting on the arm sling. R377's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2024 documents R377 was admitted to the facility following a mechanical fall and sustaining a comminuted transverse fracture of the right humeral neck. This evaluation also documents R377 has a brace and/or splint with instructions for the right shoulder sling to be worn to prevent subluxation (separation of the joint). R377's August 2024 Physician Orders do not document an order for an arm sling. On 08/20/2024 at 12:00 PM and 2:16 PM, R377 was not wearing the sling. At 2:16 PM…
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.
- Potential for harm · D2024-08-23 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management 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 observation, interview, and record review the facility failed to ensure adequate pain management was provided for one of two residents (R29) reviewed for pain on the sample list of 26. Findings Include: The facility's Pain Management Policy dated August 2017 documents the facility's mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of the policy is to accomplish that mission through an effective pain management program, providing residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The same policy documents pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. R29's Minimum Data Set (MDS) dated…
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.
- Potential for harm · D2024-08-23 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 dispose of discontinued medications for one (R9) of 22 residents reviewed for physician orders in the sample list of 26. Findings include: On 8/21/24 at 4:30 PM, the bottom drawer of the [NAME] Wing Medication Cart contained a medication bottle without a label. Inside of this bottle, there were three new Haldol {Antipsychotic} 5mg (milligrams)/ml (milliliters) vials that had a sticker on the bottles with R9's name. At this time, V2 (Director of Nursing) stated the Haldol was a one-time order and should have been destroyed or sent back to the pharmacy. R9's July 2024 Physician Order Sheet documents an order received on 7/15/2024 for Haloperidol {Haldol} Lactate Injection Solution 5mg/5ml (Haloperidol Lactate)- Inject one ml intramuscularly, every 8 hours as needed for agitation and aggression, for 14 Days with instructions of may give IM (Intramuscularly) when not given PO (by mouth). The facilities Destroying Medication policy date 9/2023 documents, all discontinued medications or medications of discharged…
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.
- Potential for harm · D2024-04-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably 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 ensure a call light was within reach for one of five residents (R1) reviewed for call lights on the sample list of seven. Findings Include: R1's ongoing and undated Medical Diagnosis Listing documents the following diagnoses: Quadriplegia, Multiple Sclerosis, Anxiety Disorder, and Neuromuscular Dysfunction of the Bladder. On 4/15/24 at 9:15 am, R1 was sitting up in a motorized wheelchair in R1's room and stated, R1 was needing R1's incontinence brief changed but that R1 can't even call them to tell them because R1's call light is hanging on the wall {behind the bed} and R1 can't reach it. At this time, R1's call light was secured to the wall, behind the head of R1's bed, out of reach and next to R1's bed was an end table, which prevented R1 from getting close enough to the wall to reach the call light. On 4/15/24 at 9:35 am, V4 CNA (Certified Nursing Assistant) and V7 RN (Registered Nurse) were in R1's room, changing R1. At this time, V4 and V7 confirmed R1's call light was secured on the wall, out of R1'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.
- Potential for harm · Dcited before2024-04-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and record review, the facility failed to prevent possible cross contamination during incontinence care for one of four residents (R1) reviewed for toileting on the sample list of seven. Findings Include: On 4/15/24 at 9:35 am, V4 CNA (Certified Nursing Assistant) and V7 RN (Registered Nurse) were changing R1's incontinence brief. R1 had been incontinent of urine and stool and R1's brief was saturated. V4 donned gloves and provided incontinence cares using disposable wipes, then proceeded to grab a clean incontinence brief and placed it under R1 without removing the potentially contaminated gloves or performing hand hygiene. R1 then urinated again, onto the new incontinence brief. V4 changed gloves at this time but did not perform hand hygiene. V4 provided incontinence care again and upon rolling R1 to R1's side, it was noted that R1 had also had another small bowel movement. V4 continued to provide incontinence care, cleaning the bowel movement, then obtained another clean brief from the bed side table and placed it under R1 without changing gloves 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.
- Potential for harm · Fcited before2023-06-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 store a frozen food item to protect from freezer damage, failed to maintain the range hood in a manner to protect foods being prepared, and failed to protect serving wares from cross contamination during meal services. These failures have the potential to affect all 79 residents residing in the facility. Findings include: On 6/6/23 at 9:35 am, the facility walk-in freezer contained an open cardboard box of frozen chicken breast fillets. Inside the cardboard box, the chicken was in a plastic bag that was wide open, exposing the chicken to the freezer air. V12, Dietary Manager, stated, We will have to get that closed up. On 6/6/23 at 9:40 am, the range exhaust hood had greasy particles and clumps of material with the appearance of lint or cobwebs. These particles and clumps were too numerous to count but several dozen were present on each of the internal slat structures of the range hood. Many, again too numerous to count, of the clumps were loosely hanging directly over the range where there was green beans…
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.
- Potential for harm · D2023-06-08 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 complete and submit a comprehensive Minimum Data Set within the 14-day requirement after determining a significant change in a resident's health status. This failure affects one resident (R28) out of three reviewed for pressure ulcers on the sample list of 28. Findings include: R28's Minimum Data Set (MDS, resident assessment instrument) dated 1/31/23 documents R28 required supervision and set up assistance to accomplish bed mobility, surface to surface transfers, ambulation in the room and corridor, eating, and toileting. This same MDS documents R28 required supervision and physical assistance from one staff member to accomplish locomotion on and off the nursing unit with a walker, and dressing. This MDS documents R28 required extensive assistance of one staff member to accomplish bathing. This MDS documents R28 is not steady in transitions such as rising from sitting to standing, walking, turning around, and during surface-to-surface transfers but 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.
- Potential for harm · D2023-06-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 revise a resident's care plan to reflect the actual level of assistance required to accomplish activities of daily living. This failure affects one resident (R37) out of three reviewed for activities of daily living on the sample list of 28. Findings include: On 6/6/23 at 3:56 pm, R37 stated, The staff have to do the shaving for me. I can transfer but I need help doing it, and I need help for showers. R37's Minimum Data Assessment (MDS, resident assessment instrument) dated 12/3/22 documents R37 required limited assistance of one staff member to accomplish bed mobility and surface to surface transfers. This same MDS documents R37 required supervision and set up assistance to accomplish locomotion in a wheelchair on the nursing unit. This same MDS documents R37 required extensive assistance of one staff member to accomplish bathing and personal hygiene. R37's MDS dated [DATE] documents R37 required extensive assistance of one staff member to accomplish…
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.
- Potential for harm · Dcited before2023-06-08 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 provide personal hygiene or grooming services to remove facial hair from a female resident. This failure affects one resident (R37) out of three reviewed for activities of daily living on the sample list of 28. Findings include: On 6/6/23 at 3:33 pm, R37 was seated in a wheelchair in R37's own room. R37 had dark colored black and gray hair below the chin in an area covering the same distance as from one corner of the mouth to the other corner of the mouth. R37 reached a hand up to stroke this under chin hair and the hair was as long as the length of R37's fingernail beds. R37 also had dark colored brown and black facial hair approximately one quarter inch long across the width of the upper lip. All this facial hair was prominently visible. On 6/6/23 at 3:33 pm, R37 stated, The staff have to do the shaving for me but sometimes it goes a while between shavings. R37's Minimum Data Set, dated [DATE] documents R37 requires extensive assistance…
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.
- Potential for harm · Dcited before2023-06-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to utilize basic infection control procedures by failing to wear gloves during the administration of a finger puncture blood glucose check and administration of an insulin injection. This failure affects one resident (R39) out of one observed for glucose checks and insulin administration on the sample list of 28. Findings include: On 6/8/23 at 12:45 pm, R39 was sitting outside the facility's entry door next to the therapy department. V20, Licensed Practical Nurse, exited the facility from this therapy door and administered a finger puncture blood glucose check without the benefit of wearing gloves. V20 returned inside the facility, then returned outside after several minutes to approach R39 and administered an insulin injection to R39 utilizing a re-useable insulin pen injection set, again without benefit of wearing gloves. V20 then placed R39's insulin pen inside V20's front lower left shirt pocket and returned inside the building. On 6/8/23 at 2:14 pm, V20, Licensed Practical Nurse, confirmed V20 had…
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.
“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.
- 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.
Fines & penalties
$19,250 in federal fines across 1 penalty.
- $19,250 — penalty dated 2026-06-17
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 ACCOLADE HEALTHCARE — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 2.5 | +0.5 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 2 of 5 | 1.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 3.2 | -0.2 vs chain |
The other 5 homes this chain runs (chain average 2.5★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| FREEDMAN, MOSHE | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 99% | since 08/02/2017 |
| ORSOWY, MALERIE | Individual | W-2 MANAGING EMPLOYEE | — | since 07/16/2018 |
CMS files one row per role, so the 3 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $449K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
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.
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 146010. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-04, 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.