Evenglow Lodge
215 East Washington, Pontiac, IL 61764 · Non profit - Other · 48 certified beds · (815) 842-4613 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- nursing-staff turnover (60%) runs well above the national median (45%)
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 | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 16.7% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 5.8% | 6.3% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.2% | 1.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.1% | 54.2% | 6.5% | better 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 | 4.2% | 3.1% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 27.2% | 14.3% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.1% | 18.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 91.8% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 31.2% | 20.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.5% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.2% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.0% | 63.1% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 4.2% | 26.1% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.1% | 13.9% | 12.0% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 8.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 37 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 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
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 | 59.1%CMS range 50.9–68.7 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.6%CMS range 7.1–16.0 | 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 | 8.1% | 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 | 2.7% | 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 | 0.0% | 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 | 97.5% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 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 | 0.0% | 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 | 5.9%CMS range 3.0–11.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.66 | 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 48 beds and averages 25.7 residents a day — about 54% occupied, or roughly 22 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 5.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.89 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.41 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 4.50 hrs/resident/day on weekends vs 5.31 on weekdays — 15% thinner on weekends. RN hours go from 1.05 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.
- Potential for harm · E2024-09-05 · 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 store resident's medications separately from food, failed to maintain a pharmacy label on medications and failed to discard/return medication for someone who was not a resident in the facility. This failure affects four residents (R11, R6, R8, R18) with medication in the medication room refrigerator in the sample list of 24. Findings include: The facility's Medication Storage Policy updated 11/1/16 documents, Medications and biologicals that are dispensed by a licensed nurse are stored in a locked cabinet/cart or locked in the medication room. On 9/3/24 at 2:38 PM, V3 (Registered Nurse) opened the medication storage room refrigerator and confirmed there is food stored in the refrigerator with resident's medications. At this time the medication storage room refrigerator contained: 1. R11's Lantus (insulin), 2. R6's Bisacodyl suppositories, 3. Two vials of Tuberculin solution, 4. Emergency stock supply of insulin and Lorazepam, 5. R8's Bisacodyl suppositories, 6. R18's Dorzolamide drops, 7. A clear plastic bag…
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 before2024-09-05 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 report a fall to the physician and resident representative for one (R12) of five residents reviewed for falls in the sample list of 24. Findings include: R12's Minimum Data Set, dated [DATE] documents R12 has moderate cognitive impairment. There is no documentation in R12's medical record that V21 (R12's Family) or V22 (R12's Physician) were notified on 5/5/24 that R12 was lowered to the floor during a staff assisted transfer. R12's Fall Report for fall on 5/5/24 documents R12's fall was not reported to V21 until 5/6/24 at 10:08 AM and V18 (Nurse Practitioner) until 5/6/24 at 8:08 AM. R12's Nursing Note dated 5/6/24 at 7:52 AM documents R12 complained of left toe discomfort and R12's left great toe and second toe were bruised/swollen. R12's Nursing Note dated 5/6/2024 at 3:47 PM documents V18 (Nurse Practitioner) evaluated R12 for toe bruising and pain and gave orders for Tylenol and foot x-ray. The Note documents R12's family was present and updated.…
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 · D2024-09-05 · 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 assistance for one (R3) of one resident reviewed for Activities of Daily Living in the sample list of 24. Findings include: On 9/03/24 at 9:28 AM R3 was sitting in the dining room and was finished with breakfast. R3's lower eyelids were very red and there was green discharge in the corner of R3's left eye. R3 stated R3's eyes have been bothering her today. R3 was asked what has been done to address R3's eye discomfort/redness/drainage. R3 stated R3 receives eye drops daily. On 9/4/24 at 9:06 AM R3 was present for the resident council meeting. R3's eyes remained red and there was white/yellow drainage on R3's eyelids. R3's Minimum Data Set, dated [DATE] documents R3 has moderate cognitive impairment and requires partial/moderate staff assistance for personal hygiene. R3's Nursing Note dated 9/3/2024 at 9:51 PM documents R3 complained of eye discomfort/pain and there was increased redness noted to R3's eyes and lower…
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 · D2024-09-05 · 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 observation, interview, and record review the facility failed to implement fall prevention interventions, failed to obtain an ordered X-ray in a timely manner, and failed to document fall and post fall assessment for two residents (R13, R12) of five residents reviewed for falls in a sample list of 24 residents. Findings Include: 1. R13's Current Diagnoses list includes the following diagnoses: Fractured Right Hip, Alzheimer's Dementia, Unsteadiness on Feet, Difficulty Walking, and Instability of Left Hip. R13's Fall Risk assessment dated [DATE] documents R13 is at moderate risk for falls. R13's Progress note dated 7/30/24 at 6:25AM by V11 (Licensed Practical Nurse/LPN) documents (R13) slid off edge of bed and was sitting next to bed. Denies any injury but complained of usual arthritic pain. Ambulated to bathroom and then out to breakfast. Narcotic pain reliever given as ordered. R13's Progress note dated 7/30/24 at 10:33 AM documents Continues to complain of pain in hips especially right and 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 before2024-09-05 · 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 observation, interview, and record review the facility failed to label and properly store nebulizer mask and tubing. The facility also failed label oxygen tubing when changed for two of two residents (R16, R3) reviewed for respiratory care in the sample list of 24. Findings include: The facility's Oxygen Policy and Procedure with a reviewed date of 12/13/23 documents, The nasal cannula or mask, the extension tubing, the pre-filled humidifier bottle and the baggie are to be changed weekly and as needed. The baggie and the pre-filled humidifier bottle are to be dated. 1.) R16's Order Summary Report dated 9/5/24 documents diagnoses including Dyspnea, Dependence of Supplemental Oxygen, Chronic Respiratory Failure with Hypoxia, Other Specified Interstitial Pulmonary Diseases, Chronic Obstructive Pulmonary Disease and Acute Upper Respiratory Infection. This Order Summary Report documents an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligrams)/3 ml (milliliters), 3 ml inhale orally every 6 hours as needed for wheezing/Shortness of Breath with a start…
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 before2024-09-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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 complete an initial assessment prior to starting an antipsychotic medication for one of five residents (R28) reviewed for unnecessary medications in the sample list of 24. Findings include: The facility's Nursing Service Procedure for Psychoactive Medication use policy with a revised date of 12/15/23 documents, Before considering the use of an anti-psychotic medication, staff will first determine whether there is an underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental cause of the behavior(s). The pre-psychoactive medication assessment form will be completed. R28's Order Summary Report dated 9/4/24 documents diagnoses including Major Depressive Disorder, Generalized Anxiety Disorder, Alzheimer's Disease with Late Onset, Dementia in Other Diseases Classified Elsewhere and Unspecified Psychosis not Due to a Substance or Known Physiological Condition. This Order Summary Report documents an order for Seroquel Oral Tablet 25 mg (milligrams) (antipsychotic) one tablet by mouth one time…
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 before2024-09-05 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review the facility failed to ensure food is handled in a sanitary manner for one (R12) of 16 residents reviewed for dining in the sample of 24. The facility's undated policy titled Handwashing, Glove Use, and Personal Standards for (facility) Foodservice, documents wear gloves when handling ready-to-eat foods. On 09/03/24 at 11:39 AM The noon meal was distributed on the second floor. V12 (Volunteer/R22's Family) was assisting staff in serving resident meal trays. R12 requested ketchup for his turkey burger. V12 touched R12's turkey burger bun with V12's bare hands and applied ketchup. On 9/03/24 at 12:00 PM V12 confirmed he volunteers at the facility and assists in serving meal trays. V12 stated V12 only wears gloves when prepping chicken on the bone. V12 confirmed V12 did not wear gloves when he touched R12's turkey burger. On 9/04/24 at 1:18 PM V6 (Dietary Manager) stated gloves should be worn when handling ready to eat foods.
- Potential for harm · Fcited before2023-11-29 · 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 ensure proper food storage by failing to label foods with a date, ensure the walk-in cooler contained a thermometer, and ensure foods were not expired prior to serving. These failures have the potential affect all 32 residents residing in the facility. Findings include: On 11/27/23 from 8:00 AM until 8:18 AM an initial tour of the kitchen was conducted. The walk-in cooler did not contain a thermometer inside the cooler. The temperature gauge on the wall located outside of the cooler next to the door was not functioning and read 0 degrees Fahrenheit (F.) The walk-in cooler contained a plastic container of mixed fruit that was covered with plastic wrap and was not labeled with a date. There were two boxes of prepared coleslaw with use by date of 11/24/23. There was an unopened plastic package of bologna lunchmeat that did not contain a use by or expiration date. Sliced ham was in a zipper locking plastic bag that was not dated. Sliced turkey was in metal roasting pans covered with plastic wrap and undated. There…
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 · F2023-11-29 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview the facility failed to implement their infection control program by failing to complete infection control logs and by failing to track, trend, and analyze infection data within the facility. This failure has the potential to affect all 32 residents that reside within the facility. Findings include: The Infection Prevention and Control Program dated 5/18/2018 documents it will include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. The facility provided their ongoing Infection Control binder that did not contain information on the culture and sensitivity of infections/pathogens, whether the infection was healthcare acquired or community acquired, nor any follow up labs after antibiotic completion. The infection control binder also did not contain a list of infections or tracking/trending data. On 11/29/23 at 1:35 PM, V4 (Infection Preventionist) stated V4 does not have any Culture and Sensitivity reports from any infection in the Infection Binder, nor did V4…
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 · D2023-11-29 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 complete a self-administration of medication assessment for residents to administer their own medication/treatments and ensure residents had an active order for the treatment for two of two residents reviewed (R1, R3) for self-administration of medications on the sample list of 25. Findings Include: The facility's Medication Administration Policy dated March 2022 documents after checking labels against the MAR (Medication Administration Record), select the appropriate medication for administration, identify the resident and observe the resident as they take the medication. 1. On 11/27/23 at 12:29 PM, R3 was sitting up in a wheelchair at the dining room table with V16 (R3's family) next to R3. R3 had a medication cup with 10 ml (milliliters) of a red liquid in the cup, without a nurse present. At this time, V16 stated that is (R3's) cough syrup that (R3) will take after (R3) is done eating. V16 also stated every time V16 is at the facility, the staff always leave it with R3 to take when R3 is done eating. 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.
Show the remaining 11 citations
- Potential for harm · Dcited before2023-11-29 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 physician and resident representative with a change in condition for one of two residents (R4) reviewed for skin alterations on the sample list of 25. Findings Include: R4's Progress Notes dated 11/15/23 by V7 (Wound Nurse) document, noted resolving blood blister {on} right foot second toe/chronic gout toe. Area is dry and intact--will use skin prep Q (every) shift x (for) 2 weeks as preventative. R4's Progress Notes from 11/15/23 - 11/27/23 do not document that R4's physician or representative were notified of R4's skin alteration. On 11/29/23 at 10:10 AM, V7 (Wound Nurse) stated the Physician or Nurse Practitioner, and the resident family are normally notified of changes in condition and that is documented in the Progress Notes but V7 did not notify them of R4's blister. Instead, V7 just initiated a standing order for skin prep due to the blister already resolving. The facility's Notification for Change in a Resident's Condition Policy dated 7/28/17 documents the attending physician and the responsible party…
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 · D2023-11-29 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 a level II PASARR (Preadmission Screening & Resident Review) was completed for one (R23) of one residents reviewed for PASARR screenings in the sample list of 25. Findings include: R23's undated Diagnoses List documents Unspecified Psychosis as of 11/1/21. R23's Interagency Certification of Screening Results dated 10/1/21 documents R23 admitted to the facility and was assessed on 10/1/21, R23 has formal diagnoses of mental illness including Chronic Depression and Panic Disorder, and a Level II Screening was not warranted or completed due to R23 being admitted for planned short term stay. There is no documentation that a Level II Screening was completed after R23 did not discharge home after R23 admitted to the facility. On 11/27/23 at 2:05 PM, V3 Social Services Director stated R23 admitted to the facility in October 2021. V3 confirmed R23's Mental Illness Diagnoses including psychosis and that R23 is a long term resident who has not discharged home after R23's admission. V3 confirmed a Level II PASARR was 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.
- Potential for harm · D2023-11-29 · 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
Based on interview and record review the facility failed to update a care plan to include interventions to prevent reoccurring Urinary Tract Infections (UTIs) and address an active infection for one (R16) of one resident reviewed for UTIs in the sample list of 25. Findings include: R16's Physician Order dated 11/22/23 documents to administer Keflex (antibiotic) 500 milligrams (mg) by mouth twice daily for 10 days for UTI. R16's Nursing Note dated 11/22/23 at 1:29 PM documents R16 had hematuria (blood-tinged urine) and abdominal discomfort. Keflex was initiated as ordered. R16's Care Plan revised 11/20/23 documents R16 has a history of frequent UTIs but does not include interventions to prevent UTIs or address R16's antibiotics for UTI treatment initiated on 11/22/23. On 11/28/23 at 12:52 PM, V8 (Minimum Data Set (MDS) Coordinator) stated V8 does not update the care plans for active infections and antibiotic use, unless it is within 30 days of the MDS completion date. V8 stated we encourage fluids as an intervention to prevent R16's reoccurring UTIs. V8 confirmed R16's care plan does…
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 · D2023-11-29 · 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
Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to complete weekly wound assessments, complete a wound treatment as ordered and prevent potential cross contamination of the wound for one of two residents (R4) reviewed for skin alterations/wounds on the sample list of 25. B. Based on interview and record review the facility failed to ensure the hospice plan of care and visit notes were part of a resident's medical record to ensure coordination of care for one (R16) of one resident reviewed for hospice in the sample list of 25. Findings Include: A.) R4's November 2023 POS (Physician Order Sheet) documents the following orders: 11/15/23 - Skin prep to the right second toe every shift for two weeks at the previous gout site which is now a resolving blister. 11/28/23 - Bacitracin Ointment 500 units/gm (gram) - apply to right second toe daily and cover with an adhesive bandage. The facility's Skin Care Record dated 11/15/23 documents Preventative care of monitoring R4's right second toe.…
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 · D2023-11-29 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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 implement physician ordered hand splints and implement restorative nursing services for range of motion and splint application following discharge from therapy services for one (R23) of one resident reviewed for range of motion in the sample list of 25. Findings include: On 11/27/23 at 11:15 AM, R23 was sitting in a wheelchair with R23's arms in a bent position, R23's hands were contracted and there was no washcloth or device in R23's palms. V18 (R23's Spouse) stated R23 has no functional movement of R23's hands. V18 demonstrated R23 required V18 to open R23's hands and R23's fingers and thumbs were stiff and contracted inward. V18 stated R23's left thumb stays in R23's palm and R23 used to use a ball in R23's palms to keep R23's hands open, but now the staff are supposed to use a rolled-up washcloth. V18 stated V11 (Restorative Certified Nursing Assistant/CNA) massages R23's hands and performs range of motion a few times per week. 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 · Dcited before2023-11-29 · 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 observation, interview and record review, the facility failed to date oxygen tubing and humidifier bottles. The facility also failed to secure and store portable oxygen cylinders appropriately for one of one resident (R4) reviewed for oxygen on the sample list of 25. Findings Include: R4's November 2023 POS (Physician Order Sheet) documents the following orders: Check R4 after meals to ensure R4's oxygen is in use, change oxygen tubing weekly and check humidification bottle daily. On 11/27/23 at 9:21 AM, R4's oxygen tubing was draped over the top of oxygen concentrator, not covered. There was no label with a date on the tubing or humidifier. On 11/28/23 at 1:21 PM, R4 was reclined back in R4's recliner with R4's oxygen tubing lying next to R4 and the oxygen concentrator on at three liters per minute. At this time, V9 (Registered Nurse/RN) reapplied the oxygen tubing and cannula onto R4. The tubing and humidifier were not dated. V9 stated the tubing and humidifier are to be dated when they are changed. Also at this time, behind R4's room door, there was a portable…
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 · D2023-11-29 · 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 observation, interview, and record review the facility failed to monitor and record fluid intake for a physician ordered fluid restriction for one (R5) of one resident reviewed for dialysis in the sample list of 25. Findings include: On 11/27/23 at 9:44 AM, R5 stated R5 receives dialysis on Tuesdays, Thursdays, and Saturdays, and R5 is on a fluid restriction. R5 stated R5's doctor tells R5 that R5 does not drink enough water. There was a water pitcher on R5's overbed table. On 11/28/23 at 9:39 AM, there was a water pitcher filled with water on R5's overbed table. On 11/29/23 at 12:17 PM, R5 was eating in the dining room. R5's meal included a disposable container of ice cream, a glass of water, and a glass of iced tea. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R5's November 2023 Physician Orders document R5 has orders for a 1500 milliliter (ml) daily fluid restriction and routine dialysis. R5's Care Plan dated 9/12/23 documents R5 has Chronic Kidney Disease Stage Four…
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 before2023-11-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to document behaviors and implement nonpharmacological interventions prior to administering psychotropic medications, failed to document clinical rational to extend an order for PRN (as needed) antianxiety medication, and failed to ensure appropriate justification for use of an antipsychotic for one (R12) of five residents reviewed for unnecessary medications in the sample list of 25. Findings include: On 11/29/23 at 9:18 AM, 9:30 AM and 10:40 AM R12 was asleep sitting in a recliner near the 2nd floor nurse's station. R12's undated Diagnoses List documents R12's diagnoses include Dementia without behavioral disturbances (5/5/16), unspecified psychosis (7/26/23), major depression, and anxiety disorder. R12's November 2023 Physician Order Summary documents orders for Celexa (antidepressant) 20 milligrams (mg) by mouth daily related to Anxiety Disorder, Lorazepam (antianxiety) 0.5 mg by mouth as needed twice daily for 120 days beginning 9/15/23,…
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 · D2023-11-29 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 according to Physician Orders and Manufacture's Recommendations for two of six residents (R11, R34) reviewed for medication administration on the sample list of 25. The facility had two errors out of 33 opportunities for a medication error rate of 6.06%. Findings Include: 1. R11's November 2023 POS (Physician Order Sheet) documents an order for Carafate (Antiulcer) 1 gm (gram) - administer one tablet before meals and at bedtime. On 11/28/23 at 11:45 am, R11 was sitting at the dining room table eating lunch and stopped V17 (Registered Nurse/RN) stating, I (R11) haven't had my Carafate yet and I'm supposed to have it 30 minutes before I eat. R11 explained R11 was served lunch around 11:30 am and has been eating since that time. V17 stated V17 forgot, even though V17 had a reminder alarm set, but would get it for R11. At 11:48 am, V17 administered R11's Carafate. The Carafate Instructions for Use dated April 2004 document Carafate is to be given on an empty stomach. 2. R34's November 2023…
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 · D2023-11-29 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
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 its Antibiotic Stewardship Program for one (R23) of three residents reviewed for antibiotic use in the sample list of 25. Findings include: The facility's Antibiotic Stewardship policy with revised date 5/8/18 documents: It is the policy that this facility's Antibiotic Stewardship Program will promote the appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use. Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility will monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. In the event that the prescribing physician orders an antibiotic without identification of infection criteria, the physician will be requested to identify rationale for ordered…
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.
- No harm found · C2024-09-05 · tag F0732 — widespreadPost nurse staffing information every day.
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 post daily staffing and include total hours worked as part of the posted daily staffing. This failure affects all 30 residents who reside in the facility. Findings include: On 9/05/24 at 9:22 AM V2 (Director of Nursing) stated posted staffing is usually located on the bulletin board by the first-floor nurse's station. V2 confirmed the bulletin board did not contain the daily posted staffing. V2 stated V14 (Scheduler) usually posts the staffing and V2 keeps the forms. V2 provided a copy of the form, which does not include the total hours worked for licensed and unlicensed staff. V1 (Administrator) stated there should be another form that is posted for daily staffing which includes the hours worked. On 9/05/24 at 9:27 AM V14 (Scheduler) stated V14 has not posted daily staffing for September 2024. V14 was completing the form, which did not include the total number of hours worked. V14 stated V14 wasn't aware that the daily posted staffing must include the hours worked. The Report of (facility) Nursing 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.
“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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| WEGNER, CYNTHIA | Individual | DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/16/2021 |
| RAY, DARRIN | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 10/01/2023 |
| ARNOLD, SHARON | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 07/01/2015 |
| DUNNING, VIRGINIA | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2023 |
| FLESSNER, CAROL | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 01/25/1992 |
| GESCHWIND, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 01/27/2003 |
| HILLMAN, MALINDA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 01/01/2021 |
| KINATE, ALBERTA | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 01/26/2009 |
| MCCOY, DOUGLAS | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 01/25/1992 |
| TAYLOR, HARLAN | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 01/24/1980 |
| TREWARTHA, JOHN | Individual | MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF | since 07/01/2015 |
| WALTER, ROBERT | Individual | MANAGING CONTROL - GOVERNING BODY | since 01/01/2021 |
CMS files one row per role, so the 24 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
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 146095. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-17, 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.